SLR - July 2022 - Stefany Carvalho, DPM
Reference: Naazie I, Arhuidese I, Zil-E-Ali A, Siracuse J, Malas M. Impact of impaired ambulatory capacity on the outcomes of peripheral vascular interventions among patients with chronic limb-threating ischemia. J Vasc Surg. 2021 Aug;74(2).Level of Evidence: Level III – Therapeutic Study
Scientific Literature Review
Review by: Stefany Carvalho, DPM
Residency Program: University Hospital – Newark, NJ
Podiatric Relevance: With increasing prevalence of peripheral artery disease, chronic limb-threatening ischemia is associated with high risk of cardiovascular events and mortality as high as 20 percent in six months of diagnosis and 50 percent in five years. In patients with impaired ambulatory and functional status, treatment becomes more challenging and fatal outcomes occur sooner and in higher rates. Prior studies show ambulatory status is a predictor of postoperative outcomes in open revascularization. Even though 77 percent of revascularizations done on non-ambulatory patients are via an endovascular approach, there is limited evidence regarding how ambulatory status impacts outcomes after minimally invasive peripheral vascular interventions.
Methods: In this study, 49,807 patients treated for chronic limb threatening ischemia from September 2016 to December 2019 were retrospectively reviewed from prospectively collected data. Outcomes assessed involved 30-day mortality and one-year amputation-free survival, in-hospital death, postoperative complications, one-year freedom from major amputation and two-year survival rate.
Results: Approximately 57 percent of patients were ambulatory and 31 percent were ambulatory with assistance, including wheelchair bound and bedridden. There was a more than two-fold increase in the odds of 30-day death in patients who were ambulatory with assistance and among wheelchair-bound patients. There was more than six-fold increase in bedridden patients compared with ambulatory patients. Compared with ambulatory patients, there was a 60 percent increase in the odds of any postoperative complication in patients who were ambulatory with assistance, and 23 percent increased odds among wheelchair bound patients. The risks of major amputation and death within one year were only 10 percent and 12 percent in ambulatory patients, while bedridden patients were as high as 30 percent and 38 percent, respectively. Amputation-free survival decreased from 81 percent with full ambulatory capacity to less than 50 percent in bedridden patients. The risk of major amputation or death within one year was 35 percent higher for ambulatory patients, 65 percent higher for wheelchair bound patients and 2.6-fold higher for bedridden patients.
Conclusions: As podiatric surgeons, these findings can contribute to improving clinician-patient conversations and shared-decision making among patients with impaired ambulatory status and chronic limb threatening ischemia considering vascular interventions. There is a relationship between increase in mortality rate and significant decrease in amputation free survival after vascular intervention in ambulatory impaired patients. Although that the goal of revascularization in non-ambulatory patients is often to relieve rest pain or heal ischemic ulcers, we need to recognize a significant proportion of these patients unfortunately result in amputation even with less invasive revascularizations. As part of the interdisciplinary medical team, the challenging discussion with non-ambulatory patients regarding pursuing primary amputation versus revascularization in the setting of advanced peripheral arterial disease needs to be actively incorporated.