Date of Award
Open Access Thesis
Medical Doctor (MD)
Cassius I. Chaar
ObjectivePatients with peripheral artery disease (PAD) present with claudication or chronic limb threatening ischemia (CLTI). CLTI patients have a more advanced stage of atherosclerosis and increased comorbidities compared to claudicants, and are at an elevated risk of major amputation and mortality after lower extremity revascularization (LER). However, the frequency of reinterventions for claudication and CLTI have not been compared. Our hypothesis is that patients with CLTI undergo more frequent reinterventions to prevent major amputation compared to patients with claudication.
MethodsA single-center retrospective chart review of consecutive patients undergoing LER for PAD in 2013-2015 was performed. Patients were stratified based on indication for revascularization into claudication or CLTI. Patient characteristics, outcomes, and reinterventions were compared between the two groups. A comprehensive literature review in PubMed was also performed to summarize the findings from the literature with respect to reinterventions for patients undergoing LER for PAD.
ResultsThere were 826 patients undergoing LER and 44% (N=361) had CLTI. Patients treated for CLTI were more likely to be smokers (p<.001), have diabetes (p<.001), chronic renal insufficiency (p<.001), end stage renal disease (p<.001), and cardiac disease (p<.001). CLTI patients were less likely to be on optimal medical management as reflected by decreased rate of aspirin (p<.001), ADP receptor/P2Y12 inhibitors (p<.001), and statins (p<.001) compared to patients with claudication. Patients with CLTI had significantly higher major amputation (3.7% vs .2%, P<.001) and mortality (1.4% vs .2%, P=.092) at 30 days. At long-term follow up, patients with CLTI had higher rates of major amputation (15.5% vs 1.3%, P < .001) and mortality (37.1% vs 18.1%, P < .001) compared to patients with claudication. There was a significant difference in mean follow-up time between the two cohorts (claudication: 3.7 ± 1.5 years vs CLTI: 2.6 ± 1.8 years, P <.001). There was no significant difference in the ipsilateral reintervention rate between the two groups (claudication: 39.6% vs CLTI: 42.7%, P=.37) or the mean number of ipsilateral reinterventions (claudication: 2.0± 1.6 vs CLTI: 2.0 ± 1.7). However, after adjusting for follow-up time, the mean number of reinterventions per year (frequency of reintervention) was significantly higher for CLTI patients compared to patients with claudication (1.4 ± 2.2 vs .6 ± 0.7 intervention per year, P <.001). The literature review yielded 96 articles which met inclusion criteria including explicit report of reintervention rate in study cohorts composed of claudication and/or CLTI patients. Of those articles with large cohort size and similar follow-up as this study, reintervention rates ranged from 11% to 41.3% in those with claudication. In those with CLTI, the range was 11.6% to 61%. Only three articles specified reintervention frequency.
Conclusion Patients undergoing LER for CLTI undergo more frequent reinterventions over time compared to patients treated for claudication. The current literature is limited to describing reintervention rates as percentage of patients undergoing any reintervention. Research on reinterventions after LER should include reporting of the frequency of reintervention adjusted for the follow up period.
Mohamedali, Alaa, "Reinterventions In Peripheral Arterial Disease: Claudication Versus Chronic Limb-Threatening Ischemia - A Retrospective Study And Review Of The Literature" (2022). Yale Medicine Thesis Digital Library. 4103.
This Article is Open Access