Treatment of Critical Limb Ischemia in Functionally Dependent Patients with Infrainguinal Disease
Cassius Iyad Ochoa Chaar, MD, MS, RPVI, Saman Doroodgar Jorshery, MD, Laura Skrip, MPH, Kristine C. Orion, MD, Timur P. Sarac, MD.
Yale University School of Medicine, New Haven, CT, USA.
|Risk Factors||Dialysis||22.1 (181)||22.2 (182)||14.6 (120)||<.001*|
|Sepsis||23.6 (193)||8.3 (68)||6.6 (54)||<.001*|
|Transfer from||Home||58.6 (479)||74 (605)||73.4 (602)||<.001*|
|Others||41.4 (339)||26 (213)||26.6 (218)|
|Outcomes||Surgical Site Infection||6.7 (55)||1.1 (9)||8.3 (68)||<.001*|
|Days from Operation to Discharge (Mean ± SD)||7.1 ± 6.2||5 ± 7.6||7.6 ± 6.1||<.001*|
|Any Readmission||14.7 (120)||22.4 (184)||20.5 (168)||.001*|
|Major Amputation||NA||2.4 (20)||3.3 (27)||.302|
|Mortality||8.2 (67)||3.9 (32)||5.9 (48)||.001*|
Objectives: Managing critical limb ischemia (CLI) remains controversial especially in dependent patients with arguable value of limb salvage. This study compares the perioperative outcomes of major amputation, bypass surgery, and endovascular intervention in dependent patients with CLI. Methods: The ACS-NSQIP files between 2012-2015 were reviewed and dependent patients (partially and totally dependent combined) with primary diagnosis of CLI were included. The patients were divided according to treatment: Major Amputation (AMP), Infrainguinal Bypass (BYP), Infrainguinal Endovascular Intervention (END). Propensity score matching based on age, gender, functional status, and American Society of Anesthesiologists (ASA) score was applied across the treatment groups. Risk factors and outcomes were compared. A multivariate logistic regression analysis with propensity score weighting was performed to identify predictors of mortality. SPSS statistical software was used. Results: After propensity matching, 2458 patients were included in the analysis. There were more women in END and more African Americans in AMP (P<.001). Patients undergoing BYP were most likely to be smokers (P<.001) while END patients were more likely to have diabetes (P<.001). END had the lowest surgical site infection (P<.001), pulmonary embolism (P=.03), urinary tract infection (P=.003), bleeding (P<.001), septic shock (P=.046), and shortest hospital stay (P<.001). AMP had significantly decreased readmission compared to BYP and END (P=.001) and decreased reoperation compared to BYP only (P<.001). Major Amputation was not different between BYP and END (P=.302). AMP had significantly higher mortality compared to END (8.2% vs 3.9%, P=.001). On multivariate regression, AMP (OR =2.28 [1.33 - 3.89]) and BYP (2.05 [1.14 - 3.71]) were at increased risk of mortality relative to END. Dialysis (OR = 2.27 [1.53 - 3.38]), sepsis (OR = 1.65 [1.05 - 2.61]), and septic shock (OR=11.22 [5.71 - 22.04]) were associated with increased odds of mortality while treating a patient transferred from home was protective (OR=.65 [.45 - .93]). Conclusion: Endovascular therapy in dependent patients with CLI has less mortality but higher readmission rate compared to amputation. For limb salvage, bypass surgery and endovascular therapy are equally effective in the short term but bypass carries significantly higher mortality and reoperations.
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