Objectives

Nonambulatory status is considered a relative contraindication for revascularization in the setting of limb-threatening peripheral arterial disease (PAD). It is common practice to amputate the affected limb without attempting an endovascular revascularization. We sought to determine whether a limb preservation procedure in this population could be justified in terms of morbidity and mortality.

Methods

From January 2012 to January 2014, 52 nonambulatory patients with severe PAD with tissue loss were divided into patients who underwent major amputation (n = 19) and endovascular revascularization for limb preservation (n = 33). Both groups were compared based on postoperative morbidity, including acute kidney injury, transfusions, acute myocardial infarction, and stroke within 1 year, and 1-year mortality. The Rutherford classification and the Society for Vascular Surgery (SVS) Lower Extremity Threatened Limb Classification were used for PAD severity classification. The revascularized patients were subdivided in patients whose limb was preserved and the patients who required a major amputation at 1 year. Multivariate Cox regression was used to evaluate the relevance between risk factors and eventual major amputation.

Results

The mean age was 69.1 for the revascularization group and 74.6 for the amputation group (P = .16). There was no significant difference in patient comorbidities in both groups, including gender, end-stage renal disease, coronary artery disease, American Society of Anesthesiologists, diabetes mellitus, and hypertension, except for hyperlipidemia being higher in the revascularized group (P = .02). SVS (P = .09) and Rutherford classification (P = .10) did not show any significant difference. Postoperative morbidity (P = .89) was similar in both groups. Mortality at 1 year was 33% in the amputated group and 12.0% in revascularized group (P =.18). SVS classification of 3 (P < .01) and Rutherford of 6 (P = .09) were significantly associated with mortality. Endovascular revascularization shows a protective effect in terms of mortality (hazard ratio [HR], 0.10; P = .10). The number of limbs needed to be revascularized to prevent one death was five (NNT= 1/[33–12]). The limb salvage at 1 year for the revascularized group was 50% (18 of 36). Factors associated with major amputation after revascularization were coronary artery disease (HR, 3.26; P = .14), end-stage renal disease (HR, 2.54; P= .27), higher TASC (HR, 2.37; P = .12), and higher SVS classification (HR, 1.05; P = .93).

Conclusions

Revascularization in nonambulatory patients is associated with a decrease in amputations and mortality at 1 year. Data suggest a protective effect is derived from revascularization even in those patients who were amputated. The high percentage of limb salvage and the NNT to prevent one death supports the use of endovascular revascularization in nonambulatory patients.

Author Disclosures: I. Iriarte: Nothing to disclose; J. L. Martinez-Trabal: Nothing to disclose; J. Ramirez- Vazquez: Nothing to disclose; R. Santini Dominguez: Nothing to disclose; S. Villarin-Ayala: Nothing to disclose.

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