Predictors for Distal Revascularization Following Femoral Endarterectomy in Chronic Limb-Threatening Ischemia Patients

Abstract

Objective This study aims to identify the clinical variables which are predictive for the benefit of concomitant distal revascularization (DR) to prevent Chronic limb-threatening ischemia (CLTI) progression and the need for major limb amputation. Methods This is a retrospective cohort study of patients who presented with lower limb ischemia and required at least femoral endarterectomy (FEA), recruited over a period of 15 years (2002-2016). The patient cohort was divided into three groups based on the type of intervention: A (FEA alone), B (FEA + catheter-based intervention/(CBI)), and C (FEA + surgical bypass (SB)). The primary endpoint was to identify independent predictors for the use of concomitant DR (CBI or SB). Secondary endpoints were amputation rate, length of stay, mortality rate, postoperative ankle-brachial index and complications, readmission rate, re-intervention rate, resolution of symptoms and wound status. Results A total of 400 patients were included, 68.0% were males. Most presenting limbs were at Rutherford class (RC) III and WIfI stage 2, with an ankle-brachial index (ABI) of .47 ± .21 and a TASC II class C lesion. No significant differences were found in the primary-assisted and secondary patency rates between the three groups ( P > .05, in all). In the multivariate analyses, clinical variables associated with DR were hyperlipidemia (hazard ratio (HR) 2.1-2.2), TASC II D (HR 2.62), Rutherford class 4 (HR 2.3) and 5 (HR 3.7), as well as WIfI stage ≥3 (HR 1.48). Conclusions Femoral endarterectomy is sufficient to treat intermittent claudication. However, patients in whom rest pain, tissue loss or TASC II D anatomic lesion severity are present may benefit from concomitant distal revascularization. Taking into consideration the overall assessment of operative risk factors for each individual patient, proceduralists should have a lower threshold for performing early or concomitant distal revascularization to reduce CLTI progression including additional tissue loss and/or major limb amputation.