CHF associated with reduced patency after peripheral endovascular intervention

Congestive heart failure (CHF) is a highly prevalent comorbidity among patients with symptomatic peripheral arterial disease. The effect of CHF on the procedural success of endovascular treatment, however, remains unknown. The details of new research from the Division of Vascular Surgery at New York Presbyterian Hospital (the Columbia and Cornell hospitals) appears in the February issue of the Journal of Vascular Surgery®.

According to co-author Andrew J. Meltzer, MD, of New York Presbyterian Hospital, CHF is associated with reduced patency after peripheral endovascular intervention and is an independent risk factor for patency loss.

"Theoretically, poor inflow secondary to systolic dysfunction and peripheral vascular alterations may predispose endovascular interventions to failure," said Dr. Meltzer. "Specifically in our study, CHF and reduced ejection fraction (EF) less than 40 percent is a strong independent risk factor for patency loss. The magnitude of this association proved greater than anticipated, specifically in the case of CHF with EF less than 40 percent, which was a greater independent predictor of patency loss than many widely accepted risk factors for poor outcome after endovascular intervention.

A retrospective review of a prospectively maintained database was performed to identify CHF patients undergoing endovascular peripheral arterial intervention from 2004 to 2009. Demographics, comorbidities, procedural details, and outcomes were analyzed. Patients underwent duplex ultrasound imaging and clinical follow-up at scheduled intervals. Kaplan-Meier and Cox proportional hazards models were used to evaluate risk factors for loss of primary patency, secondary patency and limb salvage.

Of 1,220 patients who had intervention, 271 (22 percent) with documented CHF underwent an intervention for claudication (22.5 percent) or critical limb ischemia (77.5 percent). Primary patency at 1 year was 51.9 percent ± 2.5 percent among those with CHF vs. 64.6 percent ± 1.3 percent in those without CHF; this disparity continued throughout follow-up. Patients with CHF also had reduced secondary patency throughout follow-up.

Multivariate analysis showed CHF was an independent predictor of reduced primary patency (hazard ratio [HR], 1.2; 95 percent confidence interval [CI] 1.0-1.4; P _ .038) and secondary patency (HR, 1.5; 95 percent CI, 1.2-1.8).

In the setting of CHF, 1-year patency was 56.6 percent ± 4.1 percent if the (EF) was more than 40 percent (147 patients) vs. 43.2 percent ± 3.5 percent if the EF was less than 40 percent (124 patients). Secondary patency was also significantly reduced in patients with EF less than 40 percent throughout follow-up compared with patients without CHF (949 patients) as well as those with CHF and EF more than 40 percent. Also, CHF with EF less than 40 percent was an independent predictor of reduced primary patency (HR, 1.4; 95 percent CI, 1.2-1.8) and secondary patency (HR, 1.8; 95 percent CI, 1.3-2.3.). Limb salvage was also worse in patients with EF less than 40 percent (P _ .038).

"These findings have implications for clinical practice, future research and outcomes reporting," said Dr. Meltzer. "Significant endovascular intervention is likely to remain the preferred treatment for patients with CHF given the severity of cardiopulmonary disease in these patients. Rather than withholding endovascular interventions from CHF patients, one must consider whether patients with CHF and other characteristics associated with reduced patency may benefit from a more aggressive surveillance regimen."

Dr. Meltzer added that this is a topic of ongoing study and the present findings contribute to the body of literature elucidating the risk factors for poor outcome after endovascular intervention. Therefore, future studies must document the prevalence of CHF particularly with reduced EF.

"It should not simply be viewed as comorbidity but also as a risk factor for poor outcome," noted Dr. Meltzer. "CHF and specifically heart failure with reduced EF are independent risk factors for loss of patency after endovascular intervention for symptomatic PAD. As a risk factor for patency loss, this prevalent comorbidity exceeds other generally accepted risk factors such as diabetes and anatomically challenging lesions."