IYSC05 - Critical Limb Ischemia Due to Aorto Iliac and Infrainguinal Artery Disease: Does Extensive Revascularization Warrant Limb Salvage?

Objectives: Critical limb threatening-ischemia(CLTI) can be due to extensive involvement of the aorto-iliac and infrainguinal arteries. Both districts can be revascularized simultaneously to allow flow restoration in the limb; however, revascularization confined to the aorto-iliac(AI) district can be an alternative approach, in order to reduce operation time and invasiveness. The aim of the present study was to evaluate the limb salvage in CLTI patients with both AI and infrainguinal peripheral artery disease(PAD) after revascularization confined to the AI district or extended also to the infrainguinal segment.

Methods: A retrospective analysis, including patients with CLTI and AI-PAD(TransAtlantic InterSociety Consensus: C-D) from 2016 to 2021 was performed; only patients who had also infrainguinal-PAD (Global-Anatomic-Staging-System: II-III) were included. Patients were compared according to the type of revascularization: limited to AI vs. AI-plus-infrainguinal. Perioperative mortality, limb salvage and survival were analyzed and the follow-up performed with clinical visit every six months.

Results: Over a total of 1105 peripheral revascularizations for CLTI, 96(8.7%) patients met the inclusion criteria for the present study. AI-revascularization was performed in 38(40%) and AI-plus-infrainguinal revascularization in 58(60%). The two groups were similar for preoperative risk factors and extension of PAD. The interventions in AI-revascularization group were: 38(100%) aorto-iliac angioplasty/stenting associated with common/profunda femoral artery endarterectomy in 20(52%) cases. In the AI-plus-infrainguinal revascularization group, aorto-iliac angioplasty/stenting was performed in 55(95%), aorto-bifemoral bypass in 3(5%), common/profunda femoral artery endarterectomy in 20(34%); femoro-popliteal/tibial bypass in 27(47%); and endovascular distal procedures in 31(53%) patients. The rate of minor amputation was similar between AI and AI-plus-infrainguinal revascularization (39% vs 48%, P=1.0) but a significant difference in length of stay and blood transfusion unit was detected: 7±4days vs. 12±5days, P=.04 and 2±2 vs. 4±2, P=.02, respectively. The 30-day mortality was 8% with no differences according to the type of treatment. At a mean follow-up of 36 months the overall limb salvage was 87%±4% with similar results in AI-revascularization vs AI-plus-infrainguinal revascularization (95%±5% vs 86%±6%; P=.56), the only factor associated with limb loss was a Wound-Ischemia and foot-Infection(WIfI) grade 3 (22%±7% vs. all other 0%,P=.35); overall survival was 52%±7% with preoperative hemodialysis status as the only predictor of mortality: 100% vs. 40%±7%, P=.001.

Conclusions: AI revascularization seems to have similar limb salvage and mortality if performed alone or with infrainguinal treatments. These patients have a low reduced 3-year survival(52%), which is 0% for patients in hemodialysis. The extension of the wound lesion (WiFi-3) is the main risk factor for limb loss.