SLR - April 2016 - Lisa Zhang
Title: Determinants of Survival and Major Amputation After Peripheral Endovascular Intervention for Critical Limb Ischemia
Reference: Viethaler L, Callas PW, Goodney PP, Schanzer A, Patel VI, Cronenwett J, Bertges DJ. Determinants of Survival and Major Amputation After Peripheral Endovascular Intervention for Critical Limb Ischemia. J Vasc Surg. 2015 Sep; 62(3):655-64
Scientific Literature Review
Reviewed By: Lisa Zhang, DPM
Residency Program: University Hospital, Newark NJ
Podiatric Relevance: The podiatric surgeon may be one of the first physicians to help recognize critical limb ischemia in patients with, among other symptoms, foot pain at night relieved by dependency. Rest pain along with tissue loss, unlike intermittent claudication, often leads to debilitating outcomes with at one year the patient’s likelihood to be alive at two years to be 50 percent, that of an amputation at 25 percent, and that of cardiovascular mortality at 25 percent. With the BASIL trial advocating that endovascular intervention was more suitable for older, less healthy patients who are poor candidates with limited life expectancy compared to bypass, this specific study’s objective was to analyze one-year outcomes of peripheral endovascular intervention (PVI) for critical limb ischemia (CLI).
Methods: One thousand, two hundred and forty-four patients undergoing 1414 PVIs for CLI were reviewed within the Vascular Study Group of New England (VSGNE) database, further divided into rest pain (29 percent) and tissue loss (71 percent) from January 2010 to December 2011. Exclusion criteria included claudication, acute ischemia, and aneurysmal disease and those who underwent concomitant PVI and infra-inguinal or supra-inguinal bypass. Interventions included balloon angioplasty, stent or stent graft placement, and atherectomy. Outcome measures included one-year overall survival, and freedom from major amputations.
Results: In the outcome measure of one-year survival, patients originally with tissue loss had a one-year survival rate of 80 percent, whereas the patients originally with rest pain had a oneyear survival rate of 87percent. Eight factors were found to reduce survival at a year, including dialysis dependence (P < 0.01), an emergency procedure (P = 0.046), and age > 80 years (P < 0.01). In the measure of amputation free survival, patients originally with tissue loss had amputation free survival of 71 percent, whereas the patients originally with rest pain a higher amputation free survival, that of 87 percent. Interestingly, current or former smoking as found to be protective (P = 0.042). The only common risk factor common to one-year survival and freedom from amputation was dialysis dependence (P < 0.01).
Conclusion: With mortality rates of 44 percent in one year for dialysis patients, dialysis dependence has especially poor results on survival rate and amputation free survival rate. These patients often present with multiple co-morbidities, and bypass does not often result in less sobering outcomes. It is imperative for the foot and ankle physician to work closely with vascular colleagues, not only in helping to recognize CLI – and also intermittent claudication – but also in the optimal time to amputate after re-vascularization. At our institution, amputations are done ideally as soon as possible after revascularization. CLI remains a challenging entity, but the podiatric physician working closely with vascular physician may result in optimal attempts at salving the limb.