title: Worse limb prognosis for indirect versus direct endovascular revascularization only in patients with critical limb ischemia complicated with wound infection and diabetes mellitus.
abstract: OBJECTIVE
  To investigate factors in patients with critical limb ischemia (CLI) and isolated infrapopliteal lesions that adversely affect outcomes of endovascular therapy (EVT) with or without angiosome-oriented revascularization.
  
  
  METHODS
  This was a retrospective multicenter study. We used a database of 718 consecutive CLI patients (70 ± 11 years, 75% diabetics, 68% on hemodialysis, 24% Rutherford class 6) with ischemic tissue loss due to isolated infrapopliteal lesions undergoing primary EVT. Primary outcome was MALE (major adverse limb event). Association between indirect EVT (recanalization of a non-angiosome-based artery) and outcome was assessed by Cox proportional hazard regression model.
  
  
  RESULTS
  C-reactive protein (CRP) level was >3 mg/dL in 32% of cases. Indirect EVT (in 307 CLI patients, 43%), was associated with MALE (p = .04, hazard ratio [95% confidence interval] 1.25 [1.01, 1.55]), and interacted with CRP >3 mg/dL (p < .004) but not with other baseline characteristics. Indirect EVT with CRP >3 mg/dL had higher MALE risk (HR 2.08), and interacted with diabetes mellitus (DM) presence. Indirect EVT with CRP >3 mg/dL and DM had higher MALE risk (HR 2.17).
  
  
  CONCLUSIONS
  Limb prognosis was equivalent for direct and indirect endovascular revascularization except in the presence of both diabetes and wound infection, when indirect revascularization has a poorer outcome.
authors.affiliation: Kansai Rosai Hospital Cardiovascular Center, Inabaso, Amagasaki, Hyogo, Japan. Electronic address: iida.osa@gmail.com.
authors.forename: O
authors.initials: O
authors.lastname: Iida
authors.forename: M
authors.initials: M
authors.lastname: Takahara
authors.forename: Y
authors.initials: Y
authors.lastname: Soga
authors.forename: Y
authors.initials: Y
authors.lastname: Yamauchi
authors.forename: K
authors.initials: K
authors.lastname: Hirano
authors.forename: J
authors.initials: J
authors.lastname: Tazaki
authors.forename: T
authors.initials: T
authors.lastname: Yamaoka
authors.forename: N
authors.initials: N
authors.lastname: Suematsu
authors.forename: K
authors.initials: K
authors.lastname: Suzuki
authors.forename: Y
authors.initials: Y
authors.lastname: Shintani
authors.forename: Y
authors.initials: Y
authors.lastname: Miyashita
authors.forename: M
authors.initials: M
authors.lastname: Uematsu
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood; D002097:C-Reactive Protein / Q000032:analysis; D016638:Critical Illness; D003925:Diabetic Angiopathies / Q000097:blood / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery*; D003928:Diabetic Nephropathies / Q000453:epidemiology / Q000628:therapy; D057510:Endovascular Procedures / Q000009:adverse effects*; D005260:Female; D006801:Humans; D007511:Ischemia / Q000097:blood / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery*; D007564:Japan / Q000453:epidemiology; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D016016:Proportional Hazards Models; D006435:Renal Dialysis; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014946:Wound Infection / Q000097:blood / Q000175:diagnosis / Q000453:epidemiology*
chemical_list: D015415:Biomarkers; D002097:C-Reactive Protein
keywords: Angiosome; Critical limb ischemia; Endovascular therapy