Acute limb ischemia and its predictive factors after revascularization: A single-center retrospective study from a resource-limited setting
Authors: Almadwahi Nabeel , Alhanash Sallam , Fadhel Ali , Barat Ali , Alshujaa Mohammed , Najran Mohammed , Ahmed Faisal , Altam Abdulfattah , Al-Jammal Eman , Badheeb Mohamed 
Published: August 2024

Background: Patients with acute limb ischemia (ALI) are being treated using both open and endovascular procedures, with technological developments making treatments simpler and safer. However, the most significant improvements in outcomes for these patients will come from timely diagnosis, followed by quick and standardized therapy to reduce the likelihood of limb loss and subsequent sequels. The study sought to explore the clinical presentation and treatment outcome of open surgical revascularization for ALI in a resource-limited setting.

Method: Between June 2019 and December 2022, a retrospective study including all patients presenting with ALI and treated with urgent revascularization at Al-Thora General Hospital, Sana’a, Yemen, was performed. All patients were classified using Rutherford’s ALI categorization. Demographic parameters, clinical data, treatment details, and outcomes were obtained from patient medical profiles. The main outcome was organ/patient survival and amputation 30 days following surgery. Secondary outcomes included factors associated with amputation.

Result: Overall, 91 ALI patients were treated with urgent open revascularization during the study period. The mean age of patients was 55.9 ± 11.5 years, and most cases (61.5%) were male patients. The duration of symptoms was longer than 36 h in 29 cases (31.9%). Comorbidities such as ischemic heart disease, hypertension, diabetes mellitus, hyperlipidemia, cerebrovascular disease, congestive heart failure, renal impairment, atrial fibrillation, and history of malignancy were present in 61 (67.0%), 76 (83.5%), 56 (61.5%), 49 (53.8%), 11 (12.1%), 21 (23.1%), 25 (27.5%), 47 (51.6%), and 8 (8.8%) cases, respectively. Sensory impairment was seen in 30 (33.0%) cases. Thrombosis etiology was the most common ALI causes (80.2%). In laboratory results, high C-reactive protein (CRP) levels, low hemoglobin levels (anemia), and low albumin levels were present in 15 (16.5%), 15 (16.5%), and 8 (8.8%), respectively. Most ALI (85.7%) were occurred in lower extremity. Additionally, 61 (67.0%) cases were in the Rutherford IIb stages. All cases were undergoing open surgical revascularization and fasciotomy was made in 6 (6.6%) cases. The amputation-free survival rate was 76.9% at 30 days follow-up. The 30-day outcome was amputation in 21 (23.1%) cases and death in one case. In univariate analysis, current smoking, history of diabetes, hemodialysis, history of malignancy, atrial fibrillation, sensory impairment, prolonged symptoms duration (>36 h), elevated CRP (>5 mg/L), advanced ALI stage (Rutherford’s class IIb), fasciotomy, and thrombosis etiology were associated with revascularization failure and amputation and were statistically significant (all p-values < 0.05).

Conclusion: In this study, despite no endovascular treatment offered, the application of the standard treatment—open surgical revascularization—in patients with ALI represents the key to success for limb salvage with acceptable amputation rates even in a resource-limited setting. Additionally, independent risk factors for amputation were current smoking, history of diabetes, hemodialysis, history of malignancy, atrial fibrillation, sensory impairment, prolonged symptoms duration (>36 h), elevated CRP (>5 mg/L), advanced ALI stage, fasciotomy, and thrombosis etiology. Advanced tailoring revascularization strategy and timing for the proper patient and comorbidities treatment could potentially improve amputation-free survival in ALI patients. Future studies should incorporate both limb severity and anatomic staging to best guide clinical decision-making in ALI.