Implications of early failure of isolated endovascular tibial interventions

Transitions of frailty after lower extremity interventions for chronic limb-threatening ischemia

BACKGROUND

Frailty is common among surgical patients and predicts poor surgical outcomes. This study aimed to analyze transitions in frailty state among patients undergoing lower extremity care for chronic limb-threatening ischemia (CLTI).

METHODS

Between 2018 and 2022, all patients undergoing a primary intervention for CLTI (endovascular intervention [EV], bypass [BYP], major amputation [AMP]) or wound care were analyzed. Frailty was assessed by Vascular Quality Initiative-derived Risk Analysis Index. Frailty was defined as a Vascular Quality Initiative-derived Risk Analysis Index score of ≥35. Transition in frailty state between preoperative and follow-up measurement at 1 month and 1 year were analyzed. Patient characteristics leading to a transition in frailty state were analyzed using multivariable Cox regression analysis. Amputation-free survival (survival without AMP) and freedom from major adverse limb events (above-ankle amputation of the index limb or major re-intervention (new BYP graft, jump/interposition graft revision) were evaluated.

RESULTS

We included 1859 patients (56% male; mean age, 65 ± 11 years) who underwent either EV (52%), a BYP (29%), AMP (13%), or wound care (6%). Amon them, 25% were considered frail on initial evaluation (28%, 16%, 32%, and 30% EV, BYP, AMP, and wound care, respectively). At 30 days, overall frailty increased to 34%: 13% of patients moved from nonfrail to frail (9%, 18%, 22%, and 5% for EV, BYP, AMP, and wound care, respectively), and 4% of patients moved from frail to nonfrail (6%, 2%, 1%, and 0% for EV, BYP, AMP, and wound care, respectively). At 1 year, overall frailty increased to 40%: an additional 13% of patients shifted from nonfrail to frail (15%, 6%, 23%, and 8% for EV, BYP, AMP, and wound care, respectively), and 5% of patients shifted from frail to nonfrail (4%, 8%, 2%, and 0% for EV, BYP, AMP, and wound care, respectively). At 1 year, frailty increased by 28% in EV, 16% for BYP, 32% in AMP, and 43% in wound care. Frailty at baseline, 30 days, and 1 year was associated with a high Charlson's Comorbidity Index. Shifting to a frail state postoperatively was associated with decreased survival and a lower amputation-free survival at 1 year.

CONCLUSIONS

After major interventions for CLTI at 1 year, 27% of patients shift from a nonfrail to a frail state, and 9% of patients shift from a frail to a nonfrail state with differences across modalities in comparison to wound care, where 13% of patients moved from a nonfrail to a frail state, and none shifted from a frail to a nonfrail state. Shifting to a frail state after intervention is associated with poor outcomes and should be considered when evaluating and intervention in a patient with CLTI.

Concomitant Pedal Interventions Improve Outcomes for Tibial Interventions in Chronic Limb-Threatening Ischemia

BACKGROUND

Tibial interventions for chronic limb-threatening ischemia (CLTI) are now commonplace, and poor pedal runoff is associated with worse outcomes. This study aimed to examine the impact of pedal interventions to improve poor pedal runoff on the outcomes following tibial interventions.

METHODS

A database of patients undergoing tibial interventions for CLTI at a single center between 2010 and 2022 was retrospectively queried. Patients with critical ischemia (Rutherford 5 and 6) were identified. Preintervention and postintervention angiograms were reviewed in all cases to assess pedal runoff (total = 10), resulting in 2 run-off score groups as follows: good versus poor, <7 and ≥ 7, respectively. The presence or absence of a pedal intervention then segmented the poor runoff group. Outcomes of wound healing at 3 months, amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; above ankle amputation of the index limb or major reintervention (new bypass graft and jump or interposition graft revision) were evaluated.

RESULTS

1,768 patients (63% male, age 67 ± 12 years, mean ± SD) with CLTI underwent isolated tibial intervention on a median of 2 tibial vessels. All patients had Wound, Ischemia, and foot Infection (WIfI) grade 3 and 4 disease. Preoperatively, 40% of cases had good runoff (4.4 ± 1.1, mean ± SD), 38% had poor runoff and no pedal intervention (8.6 ± 0.8; P = 0.01 compared to good runoff), and 22% had poor runoff with a concomitant pedal intervention (8.7 ± 0.6; P = 0.01 compared to good runoff). Pedal intervention was performed on a median of 2 tarsal vessels with a technical success of 91% and overall improved pedal runoff (6.5 ± 2.1; P = 0.01 vs. preoperative). Patients with a successful concomitant pedal intervention had improved 30-day MALE rate (7% vs. 12%; P = 0.001) and 30-day amputation rate (5% vs. 11%; P = 0.001) compared to the poor runoff and no pedal intervention group and were comparable to the good runoff and no pedal intervention group (7% and 5%, respectively). Ulcer healing at 3 months was improved in the poor runoff group with intervention (55%) compared to the poor runoff and no pedal intervention group (25%; P = 0.001) but remained significantly below the good runoff group (73%). At 5 years in patients with poor runoff, pedal intervention improved freedom from MALE (41 ± 8% vs. 17 ± 8% mean ± standard error of the mean (SEM); P = 0.008) and AFS (38 ± 6% vs. 11 ± 6%, mean ± SEM; P = 0.003) and these were equivalent to the good runoff group (46 ± 4% and 51 ± 5%, mean ± SEM; freedom from MALE and AFS, respectively).

CONCLUSION

Concomitant pedal intervention to improve pedal runoff in patients with poor pedal runoff during a tibial intervention for CLTI results in improved short-term and long-term outcomes and should be considered for effective limb salvage.

The Value of Restaging WIfI (Wound, Ischemia, and Foot Infection) After Initial Vascular and Podiatric Intervention

BACKGROUND

Wound, ischemia, and foot infection (WIfI) is an important staging system for diabetic patients presenting with chronic limb-threatening ischemia (CLTI) of the lower extremities (LEs). This study examines the clinical implications of restaging WIfI after initial vascular and podiatric interventions.

METHODS

A prospective database of patients undergoing vascular intervention treatment of the LE for tissue loss between 2018 and 2022 was queried. Cases were reviewed and staged preoperatively according to WIfI and then based on the WIfI restaging after primary vascular and podiatric interventions. Three groups were identified as follows: improvement of WIfI score (improved), WIfI unchanged (no change), and deterioration of WIfI score (worsened) groups. In cases of active infection, patients underwent infection control (drainage and/or amputation) followed by revascularization (endovascular or open intervention). In contrast, patients with no active infection underwent revascularization followed by podiatric intervention. Amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; above-ankle amputation of the index limb or significant reintervention [new bypass graft or jump or interposition graft revision]) were evaluated.

RESULTS

One thousand four hundred and four patients (61% male, age 64 ± 12 years, mean ± SD) presented with CLTI underwent initial vascular and/or podiatric LE interventions. On initial presentation, 37% of the patients presented with WIfI stage 3, and 63% presented with WIfI stage 4. The majority of the patients had Global Limb Anatomic Staging System (GLASS) stage III anatomic disease. Fifty-six percent of the patients had a primary infection control procedure, and 78% had a vascular intervention (71% endovascular intervention and 29% open bypass). After completing the primary podiatric and vascular procedures and restaging the WIfI score, 48% of the patients were improved, 32% were unchanged, and 20% were worsened. The postoperative change in WIfI classification impacted both 30-day rate of MALE (5% vs. 9% vs. 24% for the improved, unchanged, and worsened groups, respectively; P = 0.01) and the 30-day rate of major amputation (2% vs. 3% vs. 14% for the improved, unchanged, and upgraded groups, respectively; P < 0.02). At 5 years, freedom from MALE was progressively worse in the improved, unchanged, and worsened groups (47 ± 5% vs. 38 ± 5% vs. 23 ± 9%, respectively; mean ± standard error of the mean (SEM), P = 0.001). The 5-year AFS also deteriorated for the improved, unchanged, and worsened groups (49 ± 5% vs. 33 ± 5% vs. 19 ± 6%, respectively; mean ± SEM, P = 0.001) CONCLUSIONS: Restaging WIfI after primary vascular and podiatric intervention results in significant downgrading of WIfI staging, allows for better differentiation of 30-day outcomes, and influences freedom from MALE and AFS outcomes.

Influence of a Novel Morphology-Driven Classification on Limb Salvage after Isolated Tibial Intervention for Chronic Limb Threatening Ischemia

BACKGROUND

Infra-popliteal interventions for chronic limb-threatening ischemia (CLTI) can be impacted by the morphology of the tibial vessels. The aim of this study was to examine the impact of a novel morphology-driven classification on the outcomes of isolated tibial intervention for CLTI.

METHODS

A database of patients undergoing isolated tibial interventions for CLTI at a single center between 2010 and 2020 was retrospectively queried. Patients with isolated infra-popliteal disease were identified, and their anatomy was scored as present or absent for lesion calcification (1 point), target vessel diameter<3.0 mm (1 point), lesion length>300 mm (1 point), and poor pedal runoff score (1 point). Patients were then divided into 3 groups: low risk (0 or 1 points), moderate risk (2 points), and high risk (3 or 4 points). Intention to treat analysis by the patient was performed. Limb-based patency (the absence of reintervention, occlusion, critical stenosis [>70%], or hemodynamic compromise with ongoing symptoms of CLTI as it related to the patency of the preoperatively determined target artery pathway) was assessed. Patient-oriented outcomes of amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; above ankle amputation of the index limb or major reintervention: new bypass graft, jump/interposition graft revision) were evaluated.

RESULTS

1,607 patients (55% male, average age 60 years, 3,846 vessels) underwent tibial intervention for CLTI. The majority of the patients were diabetic and of Hispanic origin. Morphologically, 27%, 31%, and 42% of the vessels were categorized as low risk, moderate risk, and high risk, respectively. There was a significant worsening of the infra-popliteal Global Limb Anatomic Staging System (GLASS) grading as the morphological risk increased. The 30-day major adverse cardiac events (MACE) were equivalent across the groups and were under the stated objective performance goal (OPG) of ≤10%. In contrast, both the 30-day MALE and the 30-day major amputations were significantly different across the groups, with the low-risk group remaining under the OPG of ≤9% and ≤4%, respectively, while the moderate risk and high risk exceeded the goal threshold. For the OPG, freedom from MALE was 60 ± 5%, 46 ± 5%, and 22 ± 9% at 5 years for low-, moderate-, and high-risk groups, respectively (mean ± standard error of the mean; P = 0.008). Overall AFS was 55 ± 5%, 37 ± 6%, and 18 ± 7% at 5 years for low-, moderate-, and high-risk groups, respectively (mean ± standard error of the mean; P = 0.003).

CONCLUSIONS

Tibial anatomic morphology impacts isolated tibial endovascular intervention with adverse morphology associated with poorer short- and long-term outcomes. Risk stratification based on anatomic predictors should be an additional consideration as one intervenes on infra-popliteal vessels for CLTI.

Pedal medial arterial calcification influences the outcomes of isolated infra-malleolar interventions for chronic limb-threatening ischemia

OBJECTIVE

Inframalleolar disease is present in most diabetic patients presenting with tissue loss. Inframalleolar (pedal) artery disease and pedal medial arterial calcification (pMAC) are associated with major amputation in patients with chronic limb-threatening ischemia (CLTI). This study aimed to examine the impact of pMAC on the outcomes after isolated inframalleolar (pedal artery) interventions.

METHODS

A database of lower extremity endovascular intervention for patients with tissue loss between 2007 and 2022 was retrospectively queried. Patients with CLTI were selected, and those undergoing isolated inframalleolar intervention on the dorsalis pedis and medial and lateral tarsal arteries and who had foot x-rays were identified. X-rays were assessed blindly for pMAC and scored on a scale of 0 to 5. Patients with concomitant superficial femoral artery and tibial interventions were excluded. Intention to treat analysis by the patient was performed. Amputation-free survival (survival without major amputation) was evaluated.

RESULTS

A total of 223 patients (51% female; 87% Hispanic; average age, 66 years; 323 vessels) underwent isolated infra-malleolar intervention for tissue loss. All patients had diabetes, 96% had hypertension, 79% had hyperlipidemia, and 63% had chronic renal insufficiency (55% of these were on hemodialysis). Most of the patients had Wound, Ischemia, and foot Infection (WIfI) stage 3 disease and had various stages of pMAC: severe (score = 5) in 48%, moderate (score = 2-4) in 31%, and mild (score = 0-1) in 21% of the patients. Technical success was 94%, with a median of one vessel treated per patient. All failures were in severe pMAC. Overall, major adverse cardiovascular events was 0.9% at 90 days after the procedure. Following the intervention, most patients underwent a planned forefoot amputation (single digit, multiple digits, ray amputation, or trans-metatarsal amputation). WIfI ischemic grade was improved by 51%. Wound healing at 3 months was 69%. Those not healing underwent below-knee amputations. The overall 5-year amputation-free survival rate was 35% ± 9%. The severity of pMAC was associated with decreased AFS.

CONCLUSIONS

Increasing severity of pMAC influences the technical and long-term outcomes of infra-malleolar intervention in diabetes. Severe pMAC is associated with amputation and should be considered as a variable in the shared decision-making of diabetic patients with CLTI.

Successful Revascularization, Angiosome Concept, and Multivessel Revascularization: Effects on Wound Healing: An Asian Perspective

Endovascular treatment for revascularization in patients with chronic limb-threatening ischemia (CLTI), which is commonly found in patients with diabetes mellitus demonstrates a variable result of vessel patency, wound healing rate, and limb salvage rate. The angiosome concept has been adopted to determine the best target arterial path (TAP) for revascularization for wound healing in CLTI patients. Recent publications demonstrated the benefit of angiosome-targeted revascularization to guide the endovascular treatment in patients CLTI. The best TAP under angiosome concept by direct revascularization with at least 2 of 3 below-the-knee arteries runoff to restore in-line pulsatile blood flow to the ischemic tissue shows the best patency and high rate of wound healing. However, the clinical evidence and application of the angiosome concept in daily practice are difficult and not well established. The vascular territories, collateral vessel, wound area, and locations which associated with angiosome are varied. This article review aims to summarize the concept of angiosome-targeted revascularization and multivessel revascularization for application to the real-world practice under the evidence-based data.

Correlation between the vascular resistance index and arteriography for assessment of the distal arterial bed in chronic limb threatening ischemia

Background

Patients with chronic limb threatening ischemia (CLTI) of the lower limbs (LL) undergo arteriography for revascularization surgery planning. Doppler ultrasound (DU) is non-invasive and can provide information about the distal arteries through measurement of the resistance index (RI).

Objectives

To correlate the Rutherford Angiographic Classification with the RI for assessment of the distal arterial bed of the LL.

Methods

A cross-sectional study, conducted at a public tertiary hospital with 120 patients with LL CLTI, from September 2019 to April 2022. The RI of arteries that were candidates for revascularization was compared with the images of the same arteries obtained using arteriography, using the Rutherford Angiographic Classification of the distal bed.

Results

A total of 120 LL were assessed in 120 patients with a mean age of 68.6 years. The sample was 50.0% male and 90.0% of the patients in the sample were classified as Rutherford category five. The RI values found for the arteries of the leg exhibited a statistically significant positive correlation with the Rutherford Classification (anterior tibial, p< 0.01; posterior tibial, p = 0.012 fibular, p = 0.034; and dorsalis pedis, p < 0.001).

Conclusions

In this study, RIs for the arteries of the leg measured using Doppler ultrasound exhibited a positive correlation with the Rutherford Classification. This index could be useful for assessment of the distal arterial bed of the lower limbs of patients with chronic limb threatening ischemia.

Dynamic thiol-disulphide homeostasis as a biomarker for predicting the development of contrast medium-associated acute kidney injury in the endovascular treatment of peripheral arterial disease: should intravenous N-acetylcysteine be given before the procedure?

AIM

To determine the predictive ability of serum thiol-disulphide levels for contrast medium-associated acute kidney injury (CA-AKI) after endovascular treatment (EVT) of peripheral arterial disease (PAD) and evaluate the efficacy of intravenous N-acetylcysteine (NAC) in preventing CA-AKI.

MATERIAL AND METHODS

This double-blind, randomised controlled study included 85 consecutive adult patients who underwent EVT for PAD. Patients were divided into NAC negative (NAC-) and positive (NAC+) groups. While the NAC- group received only 500 ml saline, the NAC + group received 500 ml saline plus intravenous 600 mg NAC before the procedure. Intra- and intergroup patient characteristics, procedural details, preoperative thiol-disulphide levels, and ischaemia-modified albumin (IMA) levels were recorded.

RESULTS

There was a significant difference between NAC- and NAC + groups regarding native thiol, total thiol, disulphide/native thiol ratio (D/NT), and disulphide/total thiol ratio (D/TT). There was also a significant difference between the NAC- (33.3%) and NAC+ (13%) groups in CA-AKI development. Logistic regression analysis showed that the D/TT (OR 2.463) and D/NT (OR 2.121) were the most influential parameters for CA-AKI development. In the receiver operating characteristic (ROC) curve analysis, the sensitivity of native thiol to detect the development of CA-AKI was 89.1%. The negative predictive values of native thiol and total thiol were 95.6% and 94.1%, respectively.

CONCLUSION

The serum thiol-disulphide level can be used as a biomarker to detect CA-AKI development and reveal patients with a low risk for CA-AKI development before EVT of PAD. Furthermore, thiol-disulphide levels allow for the indirect quantitative monitoring of NAC. Preprocedural intravenous NAC administration significantly inhibits CA-AKI development.

Successful Peripheral Vascular Intervention in Patients with High-risk Comorbidities or Lesion Characteristics

PURPOSE OF REVIEW

Certain comorbidities and lesion characteristics are associated with increased risk for procedural complications, limb events, and cardiovascular events following peripheral vascular intervention (PVI) in patients with peripheral arterial disease (PAD). The purpose of this review is to provide an overview of high-risk modifiable and unmodifiable patient characteristics and its relative impact on clinical outcomes such as amputation risk and mortality. Furthermore, general approaches to potentially mitigating these risks through pre-intervention planning and use of modern devices and techniques are discussed.

RECENT FINDINGS

Diabetes, tobacco use, and older age remain strong risk factors for the development of peripheral arterial disease. Recent data highlight the significant risk of polyvascular disease on major limb and cardiac events in advanced PAD, and ongoing studies are assessing this risk specifically after PVI. Challenging lesion characteristics such as calcified disease and chronic total occlusions can be successfully treated with PVI by utilizing novel devices (e.g., intravascular lithotripsy, re-entry devices) and techniques (e.g., subintimal arterial "flossing" with antegrade-retrograde intervention). Understanding high-risk patient comorbidities and lesion characteristics will improve our ability to counsel and manage patients with advanced PAD. Continued device innovation and novel techniques will aid in procedural planning for successful interventions to improve clinical outcomes.