title: Clinical presentation and outcome after failed infrainguinal endovascular and open revascularization in patients with chronic limb ischemia.
abstract: OBJECTIVE
  Failure of prior endovascular (EV) interventions for chronic limb ischemia has been reported to negatively affect patency and limb salvage after subsequent revascularization procedures. The goal of our study was to compare the clinical presentation of patients who failed infrainguinal EV and open revascularizations (OR) and the effect of the initial intervention on final outcomes.
  
  
  METHODS
  From June 2001 to October 2010, 216 patients (237 limbs; 66 disabling claudication [DC], 171 critical limb ischemia [CLI]) presented with failed infrainguinal OR or EV revascularization for chronic limb ischemia. Clinical presentation, reinterventions, patency and limb salvage rates, and final outcomes were analyzed.
  
  
  RESULTS
  The EV group (n = 143) had more diabetes (44% vs 57%; P = .048) and ulcers (26% vs 38%; P = .039), whereas the OR group (n = 94) had more multilevel revascularizations (59% vs 33%; P < .001), rest pain (23% vs 9%; P = .002), and infrapopliteal interventions (58% vs 38%; P = .038). Presentation at time of failure was non-limb-threatening ischemia in 70% of DC and 16% of CLI patients (P < .001), with no difference in those initially treated with EV or OR. In CLI, 23% presented with acute limb ischemia in the OR group vs 10% in the EV group (P = .024). Early failure (<3 months) occurred in 15% of DC and in 36% of CLI patients and was more in the OR than in the EV group (30% vs 7% for DC [P = .011] and 71% vs 38% for CLI [P = .024]). Overall, 195 (82%) had attempted reinterventions (79% in DC and 85% in CLI; P = .245). In DC patients, 48% of OR had OR + EV and 26% had EV; 32% of EV had OR + EV and 47% had EV reinterventions. In CLI patients, 40% of OR had OR + EV and 42% had EV; 17% of EV had OR + EV; and 70% had EV reinterventions. A patent revascularized limb was achieved in 66% of OR and in 92% of EV patients (P < .001). Patency and limb salvage were significantly better in the EV group, mainly due to the difference in CLI patients, whereas survival was identical.
  
  
  CONCLUSIONS
  Clinical presentation after failed infrainguinal revascularization is determined by the initial indication. CLI patients are more likely to present early with acute limb ischemia, especially after OR. EV reinterventions play a significant role in the management of patients with failed revascularization, and EV failure is associated with better outcomes than those after OR failure, likely due to OR patients having more disadvantaged anatomy and advanced disease at the time of their initial presentation.
authors.affiliation: Division of Vascular Surgery, VA Western NY Healthcare System, Buffalo, NY 14215, USA. dosluoglu@yahoo.com
authors.forename: Hasan H
authors.initials: HH
authors.lastname: Dosluoglu
authors.forename: Purandath
authors.initials: P
authors.lastname: Lall
authors.forename: Raphael
authors.initials: R
authors.lastname: Blochle
authors.forename: Linda M
authors.initials: LM
authors.lastname: Harris
authors.forename: Maciej L
authors.initials: ML
authors.lastname: Dryjski
mesh_terms: D000368:Aged; D000671:Amputation, Surgical; D016009:Chi-Square Distribution; D002908:Chronic Disease; D015897:Comorbidity; D003920:Diabetes Mellitus / Q000453:epidemiology; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D006801:Humans; D007383:Intermittent Claudication / Q000401:mortality / Q000628:therapy; D007511:Ischemia / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D009518:New York / Q000453:epidemiology; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D011183:Postoperative Complications / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D017211:Treatment Failure; D014456:Ulcer / Q000401:mortality / Q000628:therapy; D014654:Vascular Patency; D014656:Vascular Surgical Procedures / Q000009:adverse effects* / Q000401:mortality