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Textbook outcomes after revascularization for chronic limb threatening ischemia (CLTI) remain rare
Cuneyt Koksoy, Ilse P Torres Ruiz, Zachary S Pallister, Ramyar Gilani, Joseph L Mills, Sr., Jayer Chung,
Division of Vascular Surgery and Endovascular Therapy, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX

Background: Suggested performance outcome metrics and traditional surgical benchmarks may be inadequate proxies for evaluating the quality of revascularization in chronic limb threatening ischemia (CLTI). Textbook outcomes (TO) following revascularization in CLTI are poorly described, and limited to cohorts studying open bypass only. We aim to propose a TO in CLTI to provide a more comprehensive evaluation of modern CLTI outcomes.Methods: A nine-year retrospective, single-center analysis of consecutive CLTI patients undergoing revascularization (open, endovascular, or hybrid) was performed. Data on demographics, length of stay, comorbidities, procedural data, Wound, Ischemia, and foot Infection (WIfI) scores, limb salvage, post-operative complications, wound-healing and survival were collected. TO was defined as a composite of survival, limb-salvage, without re-interventions (wound or vascular), freedom from major complications, < 1 wound-related procedure, and complete wound-healing at one year. Descriptive statistics and binary logistic regression were used to identify predictors of TO.Results: Over nine years, 703 CLTI patients (N=446 male; 63%, median age 69, IQR 64, 77 years; 915 limbs; median follow-up 25, IQR 11,47 months) were studied. Significant patient-level co-morbidities include diabetes mellitus (N=532, 76%); chronic kidney disease (N=451, 64%) and dialysis dependence (N=225, 32%). Initially, 915 limbs were treated with 646 (71%) endovascular, 222 (24%) open, and 47 (5%) hybrid procedures. TO was achieved in 248 limbs (27%). For the overall cohort, each component of TO at one-year were as follows: survival (n=617, 88%), limb-salvage (n=786, 86%), freedom from major postoperative complications (n=788, 86%), freedom from re-interventions (n=539, 59%), < 1 wound procedure (n=607, 66%), and complete wound healing (n=347, 62%). Univariable predictors of TO included male sex (Odds Ratio [OR] 0.9, 95% Confidence Interval [CI] 0.6-1.0, p=0.09); diabetes mellitus (OR 0.5, 95% CI 0.3-0.7, p=0.01); non-smoking (OR 1.7 95% CI 1.2-2.4, p < 0.01); Medicaid insurance (OR 0.4, 95% CI 0.15-0.90, p=0.02); dialysis dependence (OR 0.6, 95% CI 0.4-0.8, p < 0.01); atrial fibrillation (OR 0.5 95% CI 0.4-0.8, p < 0.01); anticoagulant use (OR 0.6, 95% CI 0.4-0.9, p=0.02); and WIfI Clinical Stage 1 (OR 3.2, 95% CI 1.9-5.4, p < 0.01). Multivariable analysis identified independent predictors of TO as follows: anticoagulant use (OR 0.6, 95% CI 0.4-0.9, p=0.01); WIfI Stage 1 (OR 2.3 95% CI 1.2-4.7; p < 0.02); and Medicaid insurance (OR 0.4, 95% CI 0.2-0.9; p=0.04; Table 1). Conclusions: Despite excellent survival and limb-salvage, TO was achieved in less than one-third of patients undergoing re-vascularization for CLTI. Patients with WIfI stage 1 have a greater than two-fold odds of having a TO compared to all other WIfI stages, whereas those with Medicaid insurance and/or taking oral anticoagulants were independently less likely to achieve a TO. Our data highlight the fact that current performance metrics fail to capture the true procedural burden associated with revascularization, which should be considered when educating patients, selecting patients for intervention, and outcome adjudication in clinical trials and quality assessments.
Table 1.

VariableUnadjusted HR (95% CI)P valueAdjusted HR (95% CI)P value
Insurance-Medicaid0.38 (0.15-0.90).020.38 (0.15-0.94).04
Non-Smoker1.66 (1.16-2.39).006
Diabetes0.49 (0.34-0.72)<.0010.56 (0.38-0.84).005
End stage renal disease0.57 (0.39-0.85).005
Atrial fibrillation0.55 (0.37-0.82).003
WIfI Clinical Stage-13.26 (1.93-5.46)<.0011.84 (0.75-4.49)<.001
Oral Anticoagulant use0.62 (0.42-0.92).020.57 (0.38-0.89).01


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