Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT.
Department of Surgery, Yale School of Medicine, Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT.
Ann Vasc Surg. 2021 Apr;72:166-174. doi: 10.1016/j.avsg.2020.10.004. Epub 2020 Nov 21.
Claudication has a relatively benign natural history, associated with a low risk of limb loss. However, rates of progression to chronic limb-threatening ischemia (CLTI) following lower extremity revascularization (LER) for claudication remain unclear. This study examines the long-term outcomes and risk factors associated with progression to CLTI after LER for claudication.
A single-center retrospective review of patients undergoing LER for claudication was performed from 2013-2016. Patients were stratified based on whether they progressed to CLTI or not.
There were 448 patients (502 limbs) treated for claudication, and 57 (12.7%) progressed to CLTI with a mean follow up time of 3.7 ± 1.5 years. Among patients who progressed, 23 (5.1%) developed tissue loss, 34 (7.6%) developed rest pain, and 6 (1.2%) underwent major amputation. The mean time of progression to CLTI was 1.6 ± 1.5 years after index LER. Patients who progressed to CLTI were more likely to have a history of congestive heart failure and prior open revascularizations compared with those who did not progress. There was no difference in type or level of index revascularization between the two groups and no difference in perioperative complications. Patients who developed CLTI had significantly higher rates of reinterventions and a mean number of reinterventions after index LER prior to developing CLTI compared to those who did not progress. Multivariable logistic regression demonstrated that history of congestive heart failure (OR = 2.8 [1.2-6.6]), stroke (OR = 2.6 [1.1-6.1]), prior open procedure (OR = 2.8 [1.3-5.9]) and increasing number of reinterventions after index LER (OR = 2.9 [1.5-5.7]) were independently associated with disease progression to CLTI.
Multiple reinterventions and previous open revascularization are associated with progression to CLTI following LER for claudication. Patients with atherosclerosis in the coronary and cerebrovascular beds are also more likely to have a progression of claudication to CLTI after LER.
跛行具有相对良性的自然病史，与肢体丧失的风险较低相关。然而，下肢血运重建（LER）治疗跛行后进展为慢性肢体威胁性缺血（CLTI）的比率尚不清楚。本研究检查了 LER 治疗跛行后进展为 CLTI 的长期结果和相关风险因素。
对 2013-2016 年接受 LER 治疗跛行的患者进行了单中心回顾性研究。根据是否进展为 CLTI 将患者分层。
共有 448 例（502 条肢体）患者因跛行接受治疗，57 例（12.7%）进展为 CLTI，平均随访时间为 3.7±1.5 年。在进展的患者中，23 例（5.1%）发生组织丧失，34 例（7.6%）发生静息痛，6 例（1.2%）接受了主要截肢。从指数 LER 到 CLTI 进展的平均时间为 1.6±1.5 年。与未进展的患者相比，进展为 CLTI 的患者更有可能有充血性心力衰竭和既往开放血运重建的病史。两组间指数血运重建的类型或水平无差异，围手术期并发症也无差异。发生 CLTI 的患者在发生 CLTI 之前，其指数 LER 后再次干预的比率和平均再次干预次数明显高于未进展的患者。多变量逻辑回归表明，充血性心力衰竭病史（OR=2.8[1.2-6.6]）、中风（OR=2.6[1.1-6.1]）、既往开放手术史（OR=2.8[1.3-5.9]）和指数 LER 后再次干预次数的增加（OR=2.9[1.5-5.7]）与疾病向 CLTI 的进展独立相关。
多次再干预和既往开放血运重建与 LER 治疗跛行后进展为 CLTI 相关。冠状动脉和脑血管床有动脉粥样硬化的患者在 LER 治疗跛行后也更有可能进展为 CLTI。
