Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
Department of Vascular Surgery, Saiseikai Yahata General Hospital, Kitakyushu, Japan.
Ann Vasc Surg. 2023 Aug;94:246-252. doi: 10.1016/j.avsg.2023.02.010. Epub 2023 Mar 2.
To evaluate limb salvage outcomes and risk factors for major amputation in chronic limb-threatening ischemia (CLTI) patients classified as stage 4 per the wound, ischemia, and foot infection (WIfI) classification following infrainguinal revascularization.
We retrospectively analyzed multicenter data of patients who had undergone infrainguinal revascularization for CLTI between 2015 and 2020. The endpoint was secondary major amputation defined as an above- or below-knee amputation following infrainguinal revascularization.
We analyzed 243 patients with CLTI and 267 limbs. Bypass surgery was performed in 14 (25.5%) and 120 (56.6%) limbs from the secondary major amputation and limb salvage groups, respectively (P < 0.01). Endovascular therapy (EVT) was performed in 41 limbs (74.5%) in the secondary major amputation group and 92 limbs (43.4%) in the limb salvage group (P < 0.01). The average serum albumin levels were 3.0 ± 0.6 and 3.4 ± 0.5 g/dL in the secondary major amputation and limb salvage groups, respectively (P < 0.01). The percentage of congestive heart failure (CHF) was 36.4% and 14.2% in secondary major amputation and limb salvage groups, respectively (P < 0.01). The number of limbs with infra-malleolar (IM) P0, P1, and P2 were 4 (7.3%), 37 (67.3%), and 14 (25.5%), respectively, in the secondary major amputation group and 58 (27.4%), 140 (66.0%), and 14 (6.6%), respectively, in the limb salvage group (P < 0.01). Limb salvage rates at 1 year were 91.0% and 68.6% in the bypass and EVT groups, respectively (P < 0.01). Limb salvage rates at 1 year in patients with IM P0, P1, and P2 were 91.8%, 79.9%, and 53.1%, respectively (P < 0.01). Multivariate analysis revealed that serum albumin level [hazard ratio (HR), 0.56; 95% confidence interval (CI), 0.36-0.89; P = 0.01], hypertension (HR, 0.39; 95% CI, 0.21-0.75; P < 0.01), CHF (HR, 2.10; 95% CI, 1.09-4.05; P = 0.03), wound grade (HR, 1.72; 95% CI, 1.03-2.88; P = 0.04), IM P (HR, 2.08; 95% CI, 1.27-3.42; P < 0.01), and EVT (HR, 3.31; 95% CI, 1.77-6.18; P < 0.01) as independent risk factors for secondary major amputation being required.
Among CLTI patients with WIfI stage 4, the limb salvage rate was poor in those with IM P1-2 following infrainguinal EVT. Low serum albumin levels, CHF, high wound grade, IM P1-2, and EVT were independent risk factors for CLTI patients requiring major amputation.
为了评估慢性肢体威胁性缺血（CLTI）患者在下肢血运重建后根据伤口、缺血和足部感染（WIfI）分类处于 4 期的保肢结局和主要截肢的风险因素。
我们回顾性分析了 2015 年至 2020 年间接受下肢血运重建的 CLTI 患者的多中心数据。终点是继发性主要截肢，定义为下肢血运重建后发生的膝上或膝下截肢。
我们分析了 243 例 CLTI 患者和 267 条肢体。在继发性主要截肢和保肢组中，旁路手术分别在 14（25.5%）和 120 条（56.6%）肢体中进行（P<0.01）。腔内治疗（EVT）分别在继发性主要截肢组的 41 条（74.5%）和保肢组的 92 条（43.4%）肢体中进行（P<0.01）。继发性主要截肢和保肢组的平均血清白蛋白水平分别为 3.0±0.6 和 3.4±0.5 g/dL（P<0.01）。充血性心力衰竭（CHF）的比例分别为 36.4%和 14.2%（P<0.01）。下肢亚踝（IM）P0、P1 和 P2 的肢体数量分别为继发性主要截肢组的 4（7.3%）、37（67.3%）和 14（25.5%），保肢组的 58（27.4%）、140（66.0%）和 14（6.6%）（P<0.01）。旁路和 EVT 组的 1 年保肢率分别为 91.0%和 68.6%（P<0.01）。IM P0、P1 和 P2 患者的 1 年保肢率分别为 91.8%、79.9%和 53.1%（P<0.01）。多变量分析显示血清白蛋白水平[风险比（HR），0.56；95%置信区间（CI），0.36-0.89；P=0.01]、高血压（HR，0.39；95%CI，0.21-0.75；P<0.01）、CHF（HR，2.10；95%CI，1.09-4.05；P=0.03）、伤口等级（HR，1.72；95%CI，1.03-2.88；P=0.04）、IM P（HR，2.08；95%CI，1.27-3.42；P<0.01）和 EVT（HR，3.31；95%CI，1.77-6.18；P<0.01）是 CLTI 患者需要继发性主要截肢的独立危险因素。
在 WIfI 分期为 4 期的 CLTI 患者中，下肢 EVT 后 IM P1-2 的保肢率较低。低血清白蛋白水平、CHF、高伤口分级、IM P1-2 和 EVT 是 CLTI 患者需要主要截肢的独立危险因素。
