Endovascular management of patients with critical limb ischemia

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• 作者：Mark F. Conrad MD ; MMSc ; ^a ; ^{mconrad@partners.org} ; Robert S. Crawford MD^a ; Lauren A. Hackney BS^a ; Vikram Paruchuri MD^a ; Christopher J. Abularrage MD^a ; Virendra I. Patel MD^a ; Glenn M. Lamuraglia MD^a ; Richard P. Cambria MD^a
• 刊名：Journal of Vascular Surgery
• 出版年：2011
• 出版时间：April 2011
• 年：2011
• 卷：53
• 期：4
• 页码：1020-1025
• 全文大小：516 K

文摘

Background

Although percutaneous intervention (PTA) is considered first-line therapy for peripheral vascular disease in many scenarios, its role in critical limb ischemia (CLI), wherein anatomic disease is more extensive, remains unclear. In the present study, late (5-year) clinical and patency data for PTA in CLI are defined.

Methods

From January 2002 to December 2007, 409 patients underwent infrainguinal PTA ± stent for CLI (Rutherford IV-VI) of 447 limbs. Primary patency, assisted patency, limb salvage, and survival were assessed using Kaplan-Meier. Predictors of patency, limb salvage, and death were determined using multivariate models.

Results

Demographics included age (70 ± 12 years old), diabetes (65.8 % ), and dialysis dependence (13 % ). The superficial femoral artery was treated in 58 % of the patients, 16 % were limited to the crural vessels, 38 % had multilevel treatment, and stents were placed in 26 % . Eighty percent of patients received postprocedure clopidogrel. Mean follow-up was 28 months (0-83). Five-year primary and assisted patency were 31 % ± 0.04 and 75 % ± 0.04, respectively. Limb salvage at 5 years was 74 % ± 0.038. Sixty-three patients had major amputations. Survival at 5 years was 39 % ± 0.03. Multivariate analysis identified dialysis dependence (P = .0005; 2.7 [1.6-4.8]), ≤1 vessel runoff (P = .02; 1.5 [1.1-2.0]), and warfarin use (P = .001; 1.7 [1.25-2.3]) as negative predictors of primary patency, but none of these were negative predictors of assisted patency. Dialysis dependence (P = .006; 2.5 [1.3-4.8]), female gender (P = .02; 2.0 [1.1-3.7]), and ≤1 vessel run-off (P = .04; 1.8 [1.0-3.2]) predicted limb loss. Dialysis dependence (P = .0003; 2.3 [1.5-3.5]), diabetes (P = .04; 1.5 [0.5-2.1]), and poor run-off (P = .04; 1.6 [1.2-2.1]) were predictors of mortality.

Conclusion

Although primary patency is low, excellent limb salvage rates can be achieved in patients with CLI through close follow-up and secondary interventions. These data, and the 12 % annual death rate, validate PTA as first-line therapy in patients with CLI.