SLR - October 2021 - Victor J. Putz

Impact of Impaired Ambulatory Capacity on the Outcomes of Peripheral Vascular Interventions among Patients with Chronic Limb-Threating Ischemia

Reference: Naazie IN, Arhuidese I, Zil-E-Ali A, Siracuse JJ, Malas MB. Impact of Impaired Ambulatory Capacity on the Outcomes of Peripheral Vascular Interventions among Patients with Chronic Limb-Threating Ischemia. Journal of Vascular Surgery. 2021 Aug;74(2):489–98.

Level of Evidence: Level III

Scientific Literature Review

Reviewed By: Victor J. Putz, DPM
Residency Program: McLaren Oakland Hospital, Pontiac, MI

Podiatric Relevance: Critical limb-threatening ischemia (CLTI) is an advanced stage of peripheral arterial disease (PAD), encompassing the demographics of a standard podiatric patient population. Even though prior literature recommends against limb salvage in this patient population with poor functional status such as impaired ambulation, peripheral endovascular revascularization may be favored through multi-disciplinary shared decision-making. The goal of the study was to enhance the ambulatory-impaired CLTI clinical-patient discussion when considering peripheral vascular intervention (PVI) by assessing how ambulatory status impacts postoperative and long-term outcomes.

Methods: This was a retrospective registry review of different cohorts in the Vascular Quality Initiative’s (VQI) PVI registry (49,807 patients) and contains data on demographics, medical comorbidities, ambulatory status, postoperative, and long-term follow-up outcomes. Ambulatory status was categorized into the following four groups: ambulatory (57.2 percent), ambulatory assistance (31.0 percent), wheelchair bound (10.8 percent), and bedridden (1.1 percent). The primary outcomes included 30-day mortality and one-year amputation-free survival. The secondary outcomes included postoperative complications and one-year major amputation. Multivariable logistic regression was used to adjust for potential confounding variables while studying 30-day mortality outcomes. Kaplan-Meier survival estimation and Cox regression analysis were used to study the one-year amputation-free survival outcomes.

Results: The 30-day mortality rate comparing ambulatory (1.3 percent), ambulatory with assistance (3.2 percent), wheelchair-bound (3.6 percent), and bedridden patients (9.3 percent) was found to increase as functional capacity decreased. The one-year amputation-free survival rate comparing ambulatory (90.1 percent), ambulatory with assistance (85.2 percent), wheelchair-bound (78.1 percent), and bedridden patients (69.6 percent) was found to decrease as functional capacity decreased. The odds of post-operative complications comparing ambulatory (2.7 percent), ambulatory with assistance (4.7 percent), wheelchair-bound (3.7 percent) and bedridden patients (5.1 percent) was found to increase as functional capacity decreased. The risk of major amputation at one year for ambulatory with assistance (43 percent), wheelchair-bound (75 percent) and bedridden patients (>three-fold) was higher compared to ambulatory patients.

Conclusions: Bedridden status was associated with significantly higher odds (6.3-fold) of 30-day mortality and increased risk (2.6-fold) of one-year amputation after PVI for CLTI. Proponents of PVI justify its use by stating that the goal is not to achieve limb salvage, but rather to provide relief of symptoms of CLTI such as elimination of rest pain and healing of ischemic ulcers. Because ambulatory-impaired CTLI patients have worsening prognoses despite PVI, other treatments should be investigated to improve amputation-free survival rates.

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