Ipsilateral PVI failure in patients with CLI predicts poor outcome after LEB: Study

Prior failed ipsilateral percutaneous vascular intervention (PVI) in patients with critical limb ischemia (CLI) predicts poor outcome after lower extremity bypass (LEB), according to a study from the 64th Vascular Annual Meeting presented by the Society for Vascular Surgery®.

"Often PVI is the preferred initial revascularization strategy at many centers in patients with CLI, but we sought to determine if previous failed ipsilateral, infrainguinal PVI (iiPVI) portends worsened outcomes after subsequent lower extremity bypass (LEB) in patients with CLI," said Brian W. Nolan, MD from the section of vascular surgery at Dartmouth-Hitchcock Medical Center in Lebanon, N.H. "We found that previous failed ipsilateral, infrainguinal PVI (iiPVI) predicted worsened outcomes (including both graft occlusion and major amputation) in CLI patients after subsequent LEB."

"We performed a retrospective cohort analysis of patients undergoing infrainguinal LEB for CLI between 2003-2008 using the Vascular Study Group of New England (VSGNE) database," added Dr. Nolan. The study endpoints were major amputation, graft occlusion and mortality rates at one year, and in-hospital major adverse events (MAE's). Outcomes were determined using Kaplan-Meier analysis and Cox Proportional-Hazard multivariate regression.

Of 1,153 patients who underwent LEB for CLI, 71 (6.2 percent) had a prior failed iiPVI. One year mortality and in-hospital MAE did not differ between the groups. Patients undergoing prior iiPVI had significantly higher rates of graft occlusion and amputation at one year. By multivariate analysis, independent predictors of one year LEB occlusion were prior iiPVI (HR 1.8; CI 1.1-2.9), arm vein conduit (HR 1.8; CI 1.1-2.6), and tibial outflow (HR 2.0; CI 1.4-2.9). Multivariate predictors of one year major amputation were iiPVI (HR 2.0; CI 1.0-3.7), dialysis (HR 4.2; 2.6-6.6), prior ipsilateral bypass (HR 1.7; CI 1.1-2.8), tibial outflow (HR 1.9; CI 1.3-2.9), and tissue loss (HR 1.7; CI 1.1-2.7).

This study shows that failed iiPVI is an important predictor of both graft occlusion and major amputation after LEB in CLI patient," said Dr. Nolan.

The VSGNE is a regional voluntary consortium of clinicians, hospital administrators and research personnel. It collects and exchanges information in an effort to continuously improve quality, safety, effectiveness, patient selection algorithms, and costs and care for patients with vascular disease. Its quality improvement registry has prospectively collected data on more than 12,000 patients undergoing certain vascular procedures including carotid endarterectomy, carotid stenting, lower extremity arterial bypass, and open and endovascular repair of AAA.