The Natural History and Outcomes of Endovascular Therapy for Claudication

Revascularization for claudication: Changing the natural history of a benign disease!

OBJECTIVE

The benign natural history of intermittent claudication was first documented in 1960 and has been reconfirmed in several subsequent studies. Excellent outcomes in patients with intermittent claudication can be achieved with exercise therapy and optimal medical management. Professional society guidelines have clearly stated that revascularization procedures should be performed only in patients with incapacitating claudication who have failed conservative therapy. Despite these guidelines, revascularization procedures, primarily percutaneous interventions, have been increasingly utilized in patients with claudication. Many of these patients are not even offered an attempt at medical therapy, and those who are often do not undergo a full course of treatment. Many studies document significant reintervention rates following revascularization, which are associated with increased rates of acute and chronic limb ischemia that may result in significant rates of amputation. The objectives of this study were to compare outcomes of conservative therapy to those seen in patients undergoing revascularization procedures and to determine the impact of revascularization on the natural history of claudication.

METHODS

Google Scholar and PubMed were searched for manuscripts on the conservative management of claudication and for those reporting outcomes following revascularization for claudication.

RESULTS

Despite early improvement in claudication symptoms following revascularization, multiple studies have demonstrated that long-term outcomes following revascularization are often no better than those obtained with conservative therapy. High reintervention rates (up to 43% for tibial atherectomies) result in high rates of both acute and chronic limb ischemia as compared with those patients undergoing medical therapy. In addition, amputation rates as high as 11% on long-term follow-up are seen in patients undergoing early revascularization. These patients also have a higher incidence of adverse cardiovascular events such as myocardial infarctions compared with patients treated medically.

CONCLUSIONS

Revascularization procedures negatively impact the natural history of claudication often resulting in multiple interventions, an increase in the incidence of acute and chronic limb ischemia, and an increased risk of amputation. Accordingly, informed consent requires that all patients undergoing early revascularization must be appraised of the potential negative impact of revascularization on the natural history of claudication.

Multiple Reinterventions for Claudication are Associated with Progression to Chronic Limb-Threatening Ischemia

BACKGROUND

Claudication has a relatively benign natural history, associated with a low risk of limb loss. However, rates of progression to chronic limb-threatening ischemia (CLTI) following lower extremity revascularization (LER) for claudication remain unclear. This study examines the long-term outcomes and risk factors associated with progression to CLTI after LER for claudication.

METHODS

A single-center retrospective review of patients undergoing LER for claudication was performed from 2013-2016. Patients were stratified based on whether they progressed to CLTI or not.

RESULTS

There were 448 patients (502 limbs) treated for claudication, and 57 (12.7%) progressed to CLTI with a mean follow up time of 3.7 ± 1.5 years. Among patients who progressed, 23 (5.1%) developed tissue loss, 34 (7.6%) developed rest pain, and 6 (1.2%) underwent major amputation. The mean time of progression to CLTI was 1.6 ± 1.5 years after index LER. Patients who progressed to CLTI were more likely to have a history of congestive heart failure and prior open revascularizations compared with those who did not progress. There was no difference in type or level of index revascularization between the two groups and no difference in perioperative complications. Patients who developed CLTI had significantly higher rates of reinterventions and a mean number of reinterventions after index LER prior to developing CLTI compared to those who did not progress. Multivariable logistic regression demonstrated that history of congestive heart failure (OR = 2.8 [1.2-6.6]), stroke (OR = 2.6 [1.1-6.1]), prior open procedure (OR = 2.8 [1.3-5.9]) and increasing number of reinterventions after index LER (OR = 2.9 [1.5-5.7]) were independently associated with disease progression to CLTI.

CONCLUSIONS

Multiple reinterventions and previous open revascularization are associated with progression to CLTI following LER for claudication. Patients with atherosclerosis in the coronary and cerebrovascular beds are also more likely to have a progression of claudication to CLTI after LER.

Prevalence and Outcomes of Endovascular Infrapopliteal Interventions for Intermittent Claudication

BACKGROUND

Although endovascular peripheral vascular interventions (PVI) are typically limited to vessels above the knee in intermittent claudication (IC), some patients have concomitant or isolated infrapopliteal disease with IC. The benefits and risks of undergoing tibial intervention remain unclear in IC patients. The purpose of this study is to evaluate the prevalence and outcomes of infrapopliteal PVI for IC.

METHODS

The Vascular Quality Initiative was queried for PVI procedures performed for IC between 2003 and 2018. Patients were divided into 3 groups: isolated femoropopliteal (FP), isolated infrapopliteal (IP), and combined above and below knee interventions (COM). Multivariable logistic regression models identified predictors of minor and major amputation, as well as freedom from reintervention. Kaplan-Meier plots estimate amputation-free survival.

RESULTS

We identified 34,944 PVI procedures for IC. There were 31,110 (89.0%) FP interventions, 1,045 (3.0%) IP interventions, and 2,789 (8.0%) COM interventions. Kaplan-Meier plots of amputation-free survival revealed that patients with any IP intervention had significantly higher rates of both minor and major amputation (log rank <0.001). Freedom from reintervention at 1-year was 89.2% for the FP group, 91.3% for the IP group, and 85.3% for the COM group (P < 0.0001). In multivariable analysis, factors associated with an increased risk of major amputation included isolated IP intervention (OR 6.47, 95% CI, 6.45-6.49; P < 0.0001), COM interventions (OR 2.32, 95% CI, 2.31-2.33; P < 0.0001), dialysis dependence (OR 3.34, 95% CI, 3.33-3.35; P < 0.0001), CHF (OR 1.86, 95% CI, 1.85-1.86; P = 0.021) and, nonwhite race (OR 1.64, 95% CI, 1.63-1.64; P = 0.013).

CONCLUSIONS

PVI in the infrapopliteal vessels for IC is associated with higher amputation rates. This observation may suggest the need for more careful patient selection when performing PVI in patients with IC where disease extends into the infrapopliteal level.

Incidence and Factors Associated With Major Amputation in Patients With Peripheral Artery Disease

Background:

Peripheral artery disease (PAD) is associated with increased risk of mortality, cardiovascular morbidity, and major amputation. Data on major amputation from a large randomized trial that included a substantial cohort of patients without critical limb ischemia (CLI) have not been described. The objective was to describe the incidence and types of amputations in the EUCLID trial (Examining Use of Ticagrelor in Peripheral Artery Disease) population, subcategorize amputations in the CLI versus no CLI cohorts, and describe the events surrounding major amputation.

Methods and Results:

Postrandomization major amputation was analyzed in the EUCLID trial. Patients were stratified by baseline CLI status. The occurrence of major amputation was ascertained and defined as the highest level. Perioperative events surrounding major amputation were obtained including acute limb ischemia, revascularization, and all-cause mortality. All variables were assessed for significance in univariable and multivariable models. The rate of major amputation during the course of the trial was 1.6% overall, 8.4% in the CLI at baseline group, and 1.2% in the no CLI at baseline group. The annualized rate of major amputation was 0.6% in PAD overall, 3.9% in the CLI at baseline group, and 0.5% in the no CLI at baseline group. Several factors were associated with increased risk of major amputation, including history of amputation, the presence of diabetes mellitus, baseline Rutherford category 4 to 6, and an ankle-brachial index <0.8. Factors associated with a lower risk for major amputation included prior statin use. The 30-day mortality rate after major amputation was 6.5% overall, 5.6% in the CLI at baseline group, and 6.8% in the no CLI at baseline group. The annual mortality rate following major amputation was 22.8% in the CLI at baseline group and 16.0% in the no CLI at baseline group.

Conclusions:

The risk factors for major amputation in EUCLID patients are similar to previous large registries’ reports except for diabetes mellitus in patients with CLI. The mortality following major amputation is lower in the EUCLID trial compared with registry data.

Registration:

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01732822.

Eight-year outcome after invasive treatment of infrainguinal intermittent claudication: A population-based analysis from the Swedish vascular register (Swedvasc)

OBJECTIVES

Invasive treatment of infrainguinal intermittent claudication is controversial, and long-term outcomes are scarce. The study aim was to evaluate 8 years results regarding new vascular interventions on index and contralateral limb, hospitalization, mortality, and amputation in 775 patients revascularized for infrainguinal intermittent claudication in 2009.

METHODS

Data on new vascular interventions retrieved from the Swedish vascular register (Swedvasc) were linked to the Inpatient Register and Cause of Death Register with information on hospitalizations, primary discharge diagnoses according to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), deaths, causes of death, and amputations.

RESULTS

During 8 years of follow-up, 486 new vascular interventions were performed. Patients were admitted for a total of 4662 hospitalizations and spent 25,970 days in hospital. Between 79% and 99% of surviving subjects were hospitalized each year. During follow-up, 311 (40.1%) patients died. The most common causes of hospitalization and death were cerebrovascular disease, ischemic heart disease, or other diseases of the circulatory system, causing 47.5% of hospitalizations and 42.4% of deaths. Seventy-seven major lower limb amputations were performed in 52 patients.

CONCLUSION

As patients undergoing invasive treatment of infrainguinal intermittent claudication have high morbidity and mortality, during 8 years of follow-up, the indication for invasive treatment should be carefully weighed against concomitant comorbidities and the timing of this treatment optimized with regard to the patient's possibilities to enjoy positive treatment effects on quality of life.

Combined percutaneous direct puncture of occluded artery - antegrade intervention for recanalization of below the knee arteries

PURPOSE

We aimed to assess the technical success of the combined percutaneous direct puncture of occluded artery - antegrade intervention technique, as well as the clinical effectiveness of treatment, on the basis of changes in the Rutherford classification.

METHODS

Between June 2015 and July 2018, 441 patients underwent endovascular recanalization due to lower limb peripheral arterial disease at our center. Of these, 18 patients (4%; 15 males, 3 females; mean age, 63.2 years) had failed antegrade recanalization and percutaneous retrograde access because of long segment occlusion, arterial rupture or dissection. Combined percutaneous direct puncture of occluded artery and antegrade approach was applied to these patients. Clinical follow-up examinations were performed at 1 month, 3 months, 6 months, and annually thereafter.

RESULTS

The mean follow-up period was 22.8±10.9 months. The mean procedure time was 93.6±28.2 min. Technical success was achieved in 14 patients (78%). Complete restoration of arterial flow in the punctured vessel could not be achieved in 4 patients (22%). Minor complications occurred in 4 of 18 procedures (22%). Amputation-free survival and limb salvage rates (83.3% and 100%, respectively) were the same for 12 and 24 months.

CONCLUSION

Technical success in lower limb peripheral arterial disease may be improved with the use of a combined percutaneous direct puncture of occluded artery - antegrade intervention, particularly for patients in whom other techniques are not a viable option.

Active Tobacco Use in Patients with Claudication Does Not Affect Outcomes after Endovascular Interventions

BACKGROUND

With the advent of endovascular procedures, the indications for intervention in claudicants have become less strict. Many interventionalists, however, will not intervene in patients with lifestyle-limiting claudication unless they have discontinued tobacco use. Many patients are unable to comply with this goal, and there is little published evidence to suggest that continued tobacco use results in poorer outcomes. We sought to determine if it is justified to deny this group of patients endovascular, potentially lifestyle-improving, procedures based on their outcomes.

METHODS

A retrospective chart review was performed between 2007 and 2011 at a midsize community teaching hospital. Patients included had documented lifestyle-limiting claudication, underwent endovascular therapy, and had no previous vascular intervention. Patients were divided into 2 groups: active smokers (AS) and nonsmokers (NS) including former and never smokers. The primary outcome was the need for reintervention and the secondary outcomes were the need for surgical revascularization, limb loss, myocardial infarction (MI), stroke, and death.

RESULTS

One hundred thirty-eight patients met inclusion criteria with 89 being male (64.5%). Forty-seven (34%) were active smokers versus 91 (66%) who were nonsmokers. Mean age at initial intervention for all 138 subjects was 66.34 years (standard deviation 10.7) and was not statistically different between the AS and NS groups. Mean follow-up was 3.6 years and was not significantly different between the two groups. Between the two groups (AS vs NS), there was no statistically significant difference between the rate of reintervention, surgical bypass, and limb loss. We also did not observe any significant difference in the rate of MI, stroke, or death during our follow-up period.

CONCLUSIONS

Although tobacco use has been shown to negatively impact bypass patency, our data show that it does not appear to increase the need for reintervention, conversion to open surgical revascularization, limb loss, or other morbidities in patients undergoing endovascular interventions for claudication. We continue to strongly recommend all our patients who smoke to discontinue tobacco use. Our results, however, do not support the notion that those patients who are unable to quit should be denied the potential benefit of an endovascular intervention. The most important limitation of our study is the small numbers of patients available for review. Larger studies will be necessary to confirm our findings.

Major adverse limb events and major adverse cardiac events after contemporary lower extremity bypass and infrainguinal endovascular intervention in patients with claudication

OBJECTIVE

Major adverse limb events (MALEs) and major adverse cardiovascular events (MACEs) at 30 days provide standardized metrics for comparison and have been adopted by the Society for Vascular Surgery's objective performance goals for critical limb ischemia. However, MALEs and MACEs have not been widely adopted within the claudication population, and the comparative outcomes after lower extremity bypass (LEB) and infrainguinal endovascular intervention (IEI) remain unclear. The purpose of this study was to compare MALEs and MACEs after LEB and IEI in a contemporary national cohort and to determine predictors of MALEs and MACEs after revascularization for claudication.

METHODS

A national data set of LEB and IEI performed for claudication was obtained using National Surgical Quality Improvement Program vascular targeted Participant Use Data Files from 2011 to 2014. Patients were stratified by LEB vs IEI and compared by appropriate univariate analysis. The primary outcomes were MALE (defined as untreated loss of patency, reintervention on the index arterial segment, or amputation of the index limb) and MACE (defined as stroke, myocardial infarction, or death). Multivariable logistic regression was used to identify predictors of MALEs and MACEs.

RESULTS

A total of 3925 infrainguinal revascularization procedures (2155 LEB and 1770 IEI) were performed for claudication. There was no difference in 30-day MALEs between LEB and IEI (4.0% vs 3.2%; P = .17). On multivariable logistic regression, predictors of 30-day MALEs included tibial revascularization (odds ratio [OR], 2.2; P < .0001) and prior LEB on the same arterial segment (OR, 1.8; P = .004). LEB had significantly higher 30-day MACEs (2.0% vs 1.0%; P = .01) but similar mortality (0.5% vs 0.4%; P = .6). Predictors of MACEs included LEB vs IEI (OR, 2.1; P = .01), chronic obstructive pulmonary disease (OR, 2.2; P = .01), dialysis dependence (OR, 4.4; P = .003), and diabetes (OR, 1.9; P = .02).

CONCLUSIONS

In this large national cohort, LEB and IEI for claudication are associated with similar 30-day MALEs. Tibial revascularization and revascularization after prior failed bypass predict MALEs in claudicants and should therefore be undertaken with caution. LEB was associated with more 30-day MACEs but comparable 30-day mortality compared with IEI. Patients with end-stage renal disease, chronic obstructive pulmonary disease, and diabetes are at high risk for MACEs. The risk of 30-day MACEs after LEB should be weighed against the longer term outcomes of LEB vs IEI and conservative management, particularly in these higher risk patients. This analysis helps define contemporary 30-day outcomes after infrainguinal revascularization performed for claudication and serves as a baseline with which the short-term outcomes of future treatments can be compared.