Lin Benjamin, Solano Antonio, Timaran Carlos H, Modrall J Gregory, Tsai Shirling, Kirkwood Melissa L, Ramanan Bala
School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX.
Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
J Vasc Surg. 2025 May 20. doi: 10.1016/j.jvs.2025.05.027.
Congestive heart failure (CHF) and peripheral artery disease (PAD) often coexist, with worse outcomes in patients undergoing PAD procedures. We investigated the impact of CHF on mid-term mortality and postoperative outcomes after PAD interventions.
Patients in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI)-Vascular Implant Surveillance and Interventional Outcomes Network (VISION) Medicare-linked database undergoing peripheral vascular interventions (PVIs) and lower extremity bypass (LEB) for PAD between 2010 and 2018 were grouped by CHF severity: Group 1, moderate/severe; and Group 2, none/asymptomatic/mild. We analyzed patients with chronic limb-threatening ischemia (CLTI) and intermittent claudication (IC) separately. Primary endpoints were 3-year death, major amputation, and reintervention. We performed propensity matching between groups. Kaplan-Meier, Cox proportional hazards, and Fine-Gray competing risk models were used to compare outcomes.
Of 62,129 patients with PAD and CHF, 47,457 underwent PVI (IC, n = 19,741; CLTI, n = 27,716) and 14,672 underwent LEB (IC, n = 3688; CLTI, n = 10,984). Propensity matching was performed on 418 claudicants, 1516 patients with CLTI undergoing PVI, and 378 patients with CLTI undergoing LEB. There were very few claudicants (n = 52) in Group 1 who underwent LEB, and this group was not analyzed further. The median age was 71 years; around 70% were male, White, and had coronary artery disease. On Kaplan-Meier analyses, 3-year survival favored Group 2 after both PVI and LEB for CLTI and PVI for IC. After PVI for CLTI, Group 1 had worse freedom from major amputation. On Cox regression analyses, Group 1 was associated with worse 3-year mortality after both PVI and LEB for CLTI and PVI for IC. Fine-Gray analysis for patients with CLTI showed a lower reintervention rate in Group 1 after LEB with no difference in reintervention after PVI, and no difference in major amputation after PVI or LEB. Group 1 had a lower mortality risk at 3 years for patients with CLTI after LEB (65.3%) compared with PVI (70.5%) and a similar risk of reintervention and major amputation.
CHF severity is a strong predictor of 30-day and mid-term mortality after both PVI and LEB for PAD. CHF severity did not significantly affect mid-term major or overall amputation. Conservative management should be strongly considered for claudicants with moderate to severe CHF. CHF severity by symptom status should be considered on an individualized basis when assessing preoperative risk, deciding revascularization strategy, and planning postoperative care.
充血性心力衰竭（CHF）与外周动脉疾病（PAD）常并存，接受PAD手术的患者预后较差。我们研究了CHF对PAD干预术后中期死亡率和术后结局的影响。
2010年至2018年间，在血管外科协会（SVS）血管质量倡议（VQI）-血管植入监测与介入结局网络（VISION）医疗保险关联数据库中，因PAD接受外周血管介入治疗（PVI）和下肢旁路移植术（LEB）的患者，按CHF严重程度分组：第1组，中重度；第2组，无/无症状/轻度。我们分别分析了慢性肢体威胁性缺血（CLTI）和间歇性跛行（IC）患者。主要终点为3年死亡率、大截肢和再次干预。我们在两组之间进行了倾向匹配。采用Kaplan-Meier法、Cox比例风险模型和Fine-Gray竞争风险模型比较结局。
在62129例患有PAD和CHF的患者中，47457例行PVI（IC患者19741例，CLTI患者27716例），14672例行LEB（IC患者3688例，CLTI患者10984例）。对418例跛行患者、1516例接受PVI的CLTI患者和378例接受LEB的CLTI患者进行了倾向匹配。第1组中接受LEB的跛行患者很少（n = 52），该组未进一步分析。中位年龄为71岁；约70%为男性、白人且患有冠状动脉疾病。根据Kaplan-Meier分析，对于CLTI患者，PVI和LEB术后以及IC患者PVI术后，第2组的3年生存率更高。CLTI患者接受PVI后，第1组的大截肢无事件生存率更差。根据Cox回归分析，对于CLTI患者，PVI和LEB术后以及IC患者PVI术后，第1组的3年死亡率更高。对CLTI患者的Fine-Gray分析显示，LEB术后第1组的再次干预率较低，PVI术后再次干预无差异，PVI或LEB术后大截肢无差异。与PVI（70.5%）相比，CLTI患者LEB术后第1组3年的死亡风险较低（65.3%），再次干预和大截肢风险相似。
CHF严重程度是PAD患者PVI和LEB术后30天及中期死亡率的有力预测指标。CHF严重程度对中期大截肢或总体截肢无显著影响。对于中重度CHF的跛行患者，应强烈考虑保守治疗。在评估术前风险、决定血运重建策略和规划术后护理时，应根据个体情况考虑按症状状态划分的CHF严重程度。
