Background
To evaluate limb salvage outcomes and risk factors for major amputation in chronic
limb-threatening ischemia (CLTI) patients classified as stage 4 per the wound, ischemia,
and foot infection (WIfI) classification following infrainguinal revascularization.
Methods
We retrospectively analyzed multicenter data of patients who had undergone infrainguinal
revascularization for CLTI between 2015 and 2020. The endpoint was secondary major
amputation defined as an above- or below-knee amputation following infrainguinal revascularization.
Results
We analyzed 243 patients with CLTI and 267 limbs. Bypass surgery was performed in
14 (25.5%) and 120 (56.6%) limbs from the secondary major amputation and limb salvage
groups, respectively (P < 0.01). Endovascular therapy (EVT) was performed in 41 limbs (74.5%) in the secondary
major amputation group and 92 limbs (43.4%) in the limb salvage group (P < 0.01). The average serum albumin levels were 3.0 ± 0.6 and 3.4 ± 0.5 g/dL in the
secondary major amputation and limb salvage groups, respectively (P < 0.01). The percentage of congestive heart failure (CHF) was 36.4% and 14.2% in
secondary major amputation and limb salvage groups, respectively (P < 0.01). The number of limbs with infra-malleolar (IM) P0, P1, and P2 were 4 (7.3%),
37 (67.3%), and 14 (25.5%), respectively, in the secondary major amputation group
and 58 (27.4%), 140 (66.0%), and 14 (6.6%), respectively, in the limb salvage group
(P < 0.01). Limb salvage rates at 1 year were 91.0% and 68.6% in the bypass and EVT
groups, respectively (P < 0.01). Limb salvage rates at 1 year in patients with IM P0, P1, and P2 were 91.8%,
79.9%, and 53.1%, respectively (P < 0.01). Multivariate analysis revealed that serum albumin level [hazard ratio (HR),
0.56; 95% confidence interval (CI), 0.36–0.89; P = 0.01], hypertension (HR, 0.39; 95% CI, 0.21–0.75; P < 0.01), CHF (HR, 2.10; 95% CI, 1.09–4.05; P = 0.03), wound grade (HR, 1.72; 95% CI, 1.03–2.88; P = 0.04), IM P (HR, 2.08; 95% CI, 1.27–3.42; P < 0.01), and EVT (HR, 3.31; 95% CI, 1.77–6.18; P < 0.01) as independent risk factors for secondary major amputation being required.
Conclusions
Among CLTI patients with WIfI stage 4, the limb salvage rate was poor in those with
IM P1-2 following infrainguinal EVT. Low serum albumin levels, CHF, high wound grade,
IM P1-2, and EVT were independent risk factors for CLTI patients requiring major amputation.
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Article info
Publication history
Published online: March 02, 2023
Accepted:
February 3,
2023
Received in revised form:
January 9,
2023
Received:
November 30,
2022
Publication stage
In Press Journal Pre-ProofFootnotes
Conflicts of interest: None
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Identification
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