Association of cardiac prognosis in chronic limb-threatening ischemia patients after endovascular intervention and wound, ischemia, and foot infection clinical stage
Authors: Kanda D , Anzaki K , Sonoda T , Ohmure K , Ikeda Y , Ohishi M 
Published: October 2022

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. While the WIfI clinical stage has been thought to have a prognostic value in CLTI patients, the hemodialysis and left ventricular ejection fraction (LVEF) also appear to represent pivotal factor affecting prognosis among CLTI patients. However, few reports have addressed associations between WIfI clinical stage and cardiac death.

Purpose
The purpose of this study was to investigate the patient's clinical factors including WIfI clinical stage and mortality of CLTI patients undergoing endovascular intervention based on WIfI clinical stage.

Methods
This retrospective study investigated 200 consecutive CLTI patients and we individually assessed WIfI clinical stage. We then compared mortality after endovascular intervention between a WIfI stage 1, 2 group and a stage 3, 4 group, and investigated associations 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 diabetes mellitus patients was significantly higher in the WIfI stage 3, 4 group (62% vs. 82%, p=0.003), but no differences in the rate of hemodialysis between WIfI stage 3, 4 group and WIfI stage 1, 2 group (53% vs. 37%, p=0.056). Median duration of follow-up was 966 days (IQR, 540–1268 days). Forty patients (20%) died after endovascular intervention. Incidences of all-cause and cardiac deaths were higher in the WIfI stage 3, 4 group than in theWIfI stage 1, 2 group (27% vs. 15%, p=0.047 and 12% vs. 3%, p=0.040, respectively). Kaplan–Meier analysis showed a significantly lower survival rate in the WIfI stage 3, 4 group than in theWIfI stage 1, 2 group (p=0.002 by log-rank test). Cox proportional hazard univariate analysis revealed that WIfI stage 3 or 4 [odds ratio (OR) 4.22, 95% confidence interval (CI) 1.29–13.72, p=0.012), hemodialysis (OR 4.67, 95% CI 1.28–16.96, p=0.010), LVEF (OR 0.96, 95% CI 0.92–0.99, p=0.045) were correlated to cardiac death. Multivariate analysis models using relevant factors from univariate analysis showed only WIfI stage 3 or 4 [odds ratio (OR) 3.74, 95% confidence interval (CI) 1.08–12.87, p=0.028) was significantly associated with cardiac death.

Conclusion
These results indicate that CLTI patients with high WIfI clinical stage may be associated with poor cardiac prognosis after endovascular intervention.

Funding Acknowledgement
Type of funding sources: None.