Print this pageFunctional Outcome After Revascularization for Critical Limb Ischemia - An Analysis of 1000 Consecutively Treated Lower Extremities
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Spence M. Taylor, MD, Corey A. Kalbaugh, MS, Dawn W. Blackhurst, DrPH, Anna L. Cass, MPH, E. Annie Trent, Eugene M. Langan, III, MD, David L. Cull, MD, Bruce A. Snyder, MD, Bruce H. Gray, DO, Christopher G. Carsten, III, MD.
Greenville Hospital System, Greenville, SC, USA.
BACKGROUND: When establishing reporting standards for successful lower extremity revascularization, it was assumed that arterial reconstruction patency and limb salvage would correlate with the ultimate goal of therapy, improved functional performance. In reality, factors determining functional outcome (improvement of ambulation and maintenance of independent living status) after revascularization have been poorly studied and are generally unknown. The purpose of this study was to assess the important determinants of functional outcome for patients after intervention for critical limb ischemia.
METHODS: The results of 1000 revascularized limbs (40.5% rest pain; 36.6% ischemic ulceration; 22.9% gangrene; 70.9% infrainguinal; 24.2% aortoiliac; 4.9% both; 35.9% treated by endovascular intervention; 61% treated by open surgery; and 3.1% by both) from 841 patients (mean age = 68±12 yo; 57% male; 76% Caucasian; 54.2% diabetic; 67% smokers; 12.1% ESRD on dialysis; and 34.6% with prior vascular surgery) treated using conventional therapy by a group of fellowship trained vascular surgeons at a single center were analyzed according to the type of intervention, the arterial level treated, age, race, gender, presentation, the presence of diabetes, smoking history, ESRD, coronary disease, hypertension, hyperlipidemia, obesity, COPD, previous stroke, dementia, prior vascular surgery, preoperative ambulatory status and independent living status. The technical outcomes of reconstruction patency and limb salvage as well as the functional outcomes of survival, maintenance of ambulation and independent living status were measured for each variable using Kaplan-Meier life table curves: differences assessed using the log-rank test. A Cox proportional hazards model was used to determine hazard ratios and 95% confidence intervals for all significant variables.
RESULTS: For the entire cohort, the five-year secondary patency and limb salvage rates were 64.1% and 72.1% respectively. Overall five-year functional outcomes for survival, maintenance of ambulation and independent living status were 41.9%, 70.6% and 81.3% respectively. Outcome (technical or functional) was not significantly affected by the type of treatment (endovascular or open surgery) or by the level of disease treated (aortoiliac, femoral or tibial). However, independent, statistically significant predictors of particularly poor functional outcome at presentation included impaired ambulatory ability at the time of presentation (70% late mortality, hazard ratio = 3.34; 39.5% failure to eventually ambulate, hazard ratio = 2.83; 30% loss of independent living status, hazard ratio = 7.97), the presence of dementia (73% late mortality, hazard ratio = 1.57; 41.2% failure to eventually ambulate, hazard ratio = 2.20; 46.4% loss of independent living status, hazard ratio = 5.44), and the presence of end stage renal disease (64.7% late mortality, hazard ratio = 2.25; 39.2% failure to eventually ambulate, hazard ratio = 2.29; 22.7% loss of independent living status, hazard ratio = 2.27).
CONCLUSIONS: Functional outcome for patients undergoing intervention for critical limb ischemia is not solely determined by the traditional measures of reconstruction patency and limb salvage, but by certain intrinsic patient comorbidities at the time of presentation. These findings question the benefit of our current approach to critical limb ischemia in functionally impaired, chronically ill patients - patients who undoubtedly will be more prevalent as our population ages.
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