The CHADS2 score may be a useful predictor of prognosis in chronic limb-threatening ischemia patients after endovascular intervention with and without AF
Authors: Ito N , Kanda D , Fukumoto D , Ohmure K , Ikeda Y , Ohishi M 
Published: November 2023

Abstract

Background
Chronic limb-threatening ischemia (CLTI) represents the end-stage manifestation of peripheral artery disease. Recently, the Society for Vascular Surgery established the Wound, Ischemia, and foot Infection (WIfI) classification system, focusing on disease severity rather than arterial lesion characteristics. The WIfI clinical stage has been thought to have a prognostic value in CLTI patients. While the CHADS2 score is well known to predicts ischemic stroke/transient ischemic attack in atrial fibrillation (AF) patients, the clinical significance of the CHADS2 score remains unclear in CTLI patients with and without AF.

Purpose
The purpose of this study was to investigate the patient’s clinical factors including WIfI clinical stage and CHADS2 score, and mortality of CLTI patients undergoing endovascular intervention.

Methods
This retrospective study investigated 200 consecutive CLTI patients and we individually assessed WIfI clinical stage and CHADS2 score. We then compared mortality after endovascular intervention between a WIfI stage 1, 2 group and a stage 3, 4 group, and investigated association between baseline characteristics and WIfI clinical stage 1, 2 group and a stage 3, 4 group.

Results
Among 200 patients, 123 patients (62%) showed WIfI stage 1 or 2, and the remaining 77 patients (38%) had WIfI stage 3 or 4. Age was significantly higher in the WIfI stage 3, 4 group [median 75, interquartile range (IQR) 68–82] compared with the WIfI stage 1, 2 group (median 70, IQR 63–79, p=0.004). The rate of AF patients was no difference between WIfI stage 1, 2 group and a stage 3, 4 group (59% vs 41%, p=0.84). CHADS2 score was significantly higher in the WIfI stage 3, 4 group than in the WIfI stage 1, 2 group (median 3, IQR 2–3 vs. median 2, IQR 1–2, p=0.013). Median duration of follow-up was 966 days (IQR, 540–1268 days). Forty patients (20%) died after endovascular intervention. Incidences of all-cause death were higher in the WIfI stage 3, 4 group than in the WIfI stage 1, 2 group (27% vs. 15%, p=0.047). Kaplan–Meier analysis showed a significantly lower survival rate in the WIfI stage 3, 4 group than in the WIfI stage 1, 2 group (p=0.002 by log-rank test). Cox proportional hazard univariate analysis revealed that WIfI stage 3, 4 group [Hazard ratio (HR);2.62, 95% confidence interval (CI):1.39–4.91, p=0.003], CHADS2 score (HR;1.42, 95%CI:1.08–1.82, p=0.008) were correlated to all-cause death. Multivariate analysis using relevant factors from univariate analysis showed WIfI stage 3, 4 group (HR;2.18, 95% CI:1.04–4.16, p=0.031) and CHADS2 score (HR:1.34, 95% CI:1.02–1.73, p=0.019) were significantly associated with all-cause death. A comparison of P-value for interaction of WIfI stage 3, 4 group and CHADS2 score was p=0.17.

Conclusion
CHADS2 score may be a crucial independent predictor for incidence of all-cause death in CLTI patients undergoing endovascular intervention with and without AF.