Predictors of limb loss despite a patent endovascular-treated arterial segment

Objective

The goal of this study was to assess the frequency and predictors of major amputation with patent endovascular-treated arterial segments (PETAS) in patients with critical limb ischemia.

Methods

The study included 358 consecutive patients (412 limbs) who underwent endovascular (236 limbs) or open (176 limbs) revascularizations for critical limb ischemia from June 2001 through May 2007. Patients with limb loss despite PETAS were compared with the rest of the endovascular-treated group (EV-other, n = 212) and with those who underwent amputations with patent bypasses (APB).

Results

The EV group underwent 30 amputations (24 in PETAS, 6 in EV-other), and 37 occurred in the open group (14 in APB, 23 in open-other). Amputations occurring despite a patent revascularized segment constituted 38% of limb loss in open and 80% in EV-treated patients (P = .001). Limb loss occurred earlier in the PETAS group (58% vs 30% ≤3 months). Primary indications for limb loss in the PETAS group were extensive tissue loss or limb dysfunction after radical débridement of infection or gangrene (37%), recurrent infection (42%), and failure to reverse ischemia (21%). There were more patients with diabetes in PETAS group (96%) than in the APB group (64%, P = .018). Diabetes, dialysis-dependence, lower albumin level, gangrene, and infrapopliteal interventions were more likely in the PETAS group than in the EV-other group. Multivariate analysis showed diabetes (odds ratio [OR], 3.15; 95% confidence interval [CI], 1.22-8.13, P = .018), gangrene (OR, 3.33; 95% CI, 1.43-7.75; P = .005), and infrapopliteal interventions (OR, 3.09; 95% CI, 1.38-6.94; P = .006), predicted limb loss with patent open or EV-treated segments, whereas dialysis-dependence, peroneal artery-only runoff, albumin level <3 g/dL, location at the heel, and treatment type did not.

Conclusions

Amputation despite PETAS is the most common means of limb loss in patients undergoing endovascular revascularization for limb salvage. It is likely the result of aggressive attempts at limb salvage and usually occurs ≤3 months after the intervention. Patients with diabetes and gangrene undergoing infrapopliteal interventions are at a significantly high risk. Adjuncts to reduce tissue loss, preserve limb function, and prevent recurrent infection are needed to prevent limb loss despite PETAS, especially in diabetic patients.