Failure to achieve clinical improvement despite graft patency in patients undergoing infrainguinal lower extremity bypass for critical limb ischemia.
OBJECTIVE
Studies of infrainguinal lower extremity bypass for critical limb ischemia (CLI) have traditionally emphasized outcomes of patency, limb salvage, and death. Because functional outcomes are equally important, our objectives were to describe the proportion of CLI patients who did not achieve symptomatic improvement 1 year after bypass, despite having patent grafts, and identify preoperative factors associated with this outcome.


METHODS
The prospectively collected Vascular Study Group of Northern New England database was used to identify all patients with elective infrainguinal lower extremity bypass for CLI (2003 to 2007) for whom long-term follow-up data were available. The primary composite study end point was clinical failure at 1 year after bypass, defined as amputation or persistent or worsened ischemic symptoms (rest pain or tissue loss), despite a patent graft. Variables identified on univariate screening (inclusion threshold, P < .20) were included in a multivariable logistic regression model to identify independent predictors.


RESULTS
Long-term follow-up data were available for 1012 patients who underwent infrainguinal bypasses for CLI, of which 788 (78%) remained patent at 1 year. Of these, 79 (10%) met criteria for the composite end point of clinical failure: 21 (2.7%) for major amputations and 58 (7.4%) for persistent rest pain or tissue loss. In multivariable analysis, significant predictors of clinical failure included dialysis dependence (odds ratio [OR], 3.74; 95% confidence interval [CI], 1.84-7.62; P < .001) and preoperative inability to ambulate independently (OR, 2.17; 95% CI, 1.26-3.73; P = .005). A history of coronary artery bypass graft or percutaneous coronary intervention was protective (OR, 0.52; 95% CI, 0.29-0.93; P = .03).


CONCLUSIONS
After infrainguinal lower extremity bypass for CLI, 10% of patients with a patent graft did not achieve clinical improvement at 1 year. Preoperative identification of this specific patient subgroup remains challenging. To improve surgical decision making and the overall care of CLI patients, further emphasis needs to be placed on functional outcomes in addition to traditional surgical end points.
Simons
Jessica P
JP
Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass 01655, USA.
Goodney
Philip P
PP
Nolan
Brian W
BW
Cronenwett
Jack L
JL
Messina
Louis M
LM
Schanzer
Andres
A
D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D016009:Chi-Square Distribution; D016638:Critical Illness; D005260:Female; D006801:Humans; D007511:Ischemia / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D023821:Limb Salvage; D016015:Logistic Models; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D009511:New England / Q000453:epidemiology; D016017:Odds Ratio; D018579:Patient Selection; D020127:Recovery of Function; D012042:Registries; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D017211:Treatment Failure; D014654:Vascular Patency; D014656:Vascular Surgical Procedures / Q000009:adverse effects* / Q000401:mortality
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