Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 58-62

A comparative study of postrevascularization limb salvage rate in early versus delayed presentation of rutherford class IIb acute lower extremity ischemia


Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India

Date of Submission17-Aug-2019
Date of Decision15-Oct-2019
Date of Acceptance04-Jan-2020
Date of Web Publication16-Mar-2020

Correspondence Address:
Dr. Hemant Kadu Chaudhari
Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_53_19

Rights and Permissions
  Abstract 


Background: Acute limb ischemia (ALI) is the most common vascular emergency with potential morbidity and mortality, which can be prevented by early appropriate treatment. Delayed presentation because of diagnostic delays and referrals continues to be a challenge for vascular surgeons. The purpose of this study is to evaluate the postrevascularization limb salvage rate in patients with delayed presenting ALI Rutherford Class IIb and compare it with early presenting ALI in a tertiary referral center in India. Materials and Methods: Fifty-one patients with Rutherford Class IIb acute lower limb ischemia, who underwent revascularization over a period of 2 years from June 2015 to May 2017 at Jain Institute of Vascular Sciences, Bengaluru, were evaluated in this study. Patients were divided into early presenting (<24 h) (n = 10) and delayed presenting (>24 h–14 days) (n = 41), and both the groups were compared with respect to limb salvage at 1 year. Patients with prior vascular intervention, posttraumatic ALI, and Rutherford Class I, IIa, and III were excluded. Results: Both the groups were comparable with respect to demographics, lesion characteristics, and comorbidities. The mean age in the early and delayed presenting groups was similar. Majority of the patients were male. The most common level of occlusion was femoropopliteal segment. All patients underwent transfemoral/transpopliteal thrombectomy + angioplasty/stenting. Fasciotomy was performed in almost half of the patients based on clinical need. The limb salvage rate was 91.67% in the early presenting group, whereas in the delayed presenting group, it was 72.73%, but the difference was not statistically significant (P = 0.178). None of the patients in the early presenting group had morality, whereas it was 12.20% in the delayed group, which was statistically not significant (P = 0.249). Conclusion: In patients with Rutherford Class IIb ALI in spite of delayed presentation, good limb salvage rate can be achieved if revascularized.

Keywords: Acute limb ischemia, delayed presentation, limb salvage rate, Rutherford Class IIb


How to cite this article:
Chaudhari HK, Vivekanand, Motukuru V, Sumanthraj K B, Rodney S R, Vishal H. A comparative study of postrevascularization limb salvage rate in early versus delayed presentation of rutherford class IIb acute lower extremity ischemia. Indian J Vasc Endovasc Surg 2020;7:58-62

How to cite this URL:
Chaudhari HK, Vivekanand, Motukuru V, Sumanthraj K B, Rodney S R, Vishal H. A comparative study of postrevascularization limb salvage rate in early versus delayed presentation of rutherford class IIb acute lower extremity ischemia. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Apr 8];7:58-62. Available from: http://www.indjvascsurg.org/text.asp?2020/7/1/58/280675




  Introduction Top


Acute limb ischemia (ALI) is one of the most common vascular emergencies as it is both limb and life threatening.[1]

Conventionally, ALI has been treated with systemic anticoagulation and early appropriate intervention. Rutherford Category I ALI is commonly treated conservatively with anticoagulation alone, whereas Rutherford Category III usually requires primary amputation. Revascularizations are most commonly warranted in Rutherford Category II ALI patients: marginally threatened IIa – salvageable if promptly treated and immediately threatened IIb – should be revascularized emergently, to achieve best results.[2] However, in Indian scenario, most of the patients present late because of delay in diagnosis, especially in those who are initially evaluated at a peripheral hospital without a dedicated vascular surgeon.[1],[2]

The purpose of this study is to evaluate the postrevascularization limb salvage rate in patients with delayed presenting ALI Rutherford Class IIb and compare it with early presenting ALI in a tertiary referral center in India.


  Materials and Methods Top


Study design

It is a single-center, retrospective, comparative study of prospectively collected data comprising 51 patients of acute lower limb ischemia Rutherford Class IIb who presented between June 2015 and May 2017 at Jain Institute of Vascular Sciences, Bengaluru.

Inclusion criteria

  1. Patients with acute lower limb ischemia (new onset, sudden, severe pain of <14 days) during the study period who underwent thrombectomy with or without endovascular procedure
  2. >18 years old
  3. Rutherford Class IIb ischemia.


Exclusion criteria

  1. Rutherford Class I, IIa, and III ischemia
  2. Prior vascular intervention
  3. Traumatic and iatrogenic ALI
  4. Lost to follow-up.


Patient selection and methodology

During study period, 182 patients with ALI were admitted in our institute, of which 62 patients with upper limb ALI, 19 patients with posttraumatic ALI, nine patients with prior vascular intervention, 5 patients with Rutherford Class I ischemia, 16 patients with Rutherford Class IIa, and 9 patients with Rutherford Class III (nonsalvageable) who offered primary amputation were excluded. Out of the remaining 62 patients with Rutherford Class IIb ALI, 11 patients were lost to follow-up (two patients at the 3rd month, three at the 6th month, and six at 1 year). Hence, 51 patients were analyzed who underwent lower limb thrombectomy ± endovascular procedure.

Out of 51 study population, only 5 patients presented within 6-h symptoms, whereas 46/51 presented beyond 6 h. As 5 versus 46 patients were not comparable, a cutoff of 24 h for early and delayed presentation was taken into consideration.[3],[4] Thus, 51 patients (61 limbs) were divided into early presenting ALI (within 24 h after onset of symptoms) (n = 10 patients and 12 limbs) and delayed presenting (>24 h–14 days after onset of symptoms) (n = 41 patients and 49 limbs) and compared with respect to postrevascularization limb salvage rate between the two groups at the end of 1 year [Figure 1].
Figure 1: Patient selection flowchart acute limb ischemia

Click here to view


Patients who died were excluded for limb-related outcome analysis (five patients in the delayed presenting group), so limb salvage and amputation analysis were derived for 12 limbs in the early presenting group and 44 limbs in the delayed presenting group.

Preoperative management

All patients had been administered with heparin 80 unit/kg bolus dose, followed by infusion at 18 unit/kg/hr in emergency. All patients were started on hydration and Foley catheterization was done. Preoperatively appropriate blood tests including creatinine phosphokinase and two-dimensional echo were done on an urgent basis. All patients underwent imaging in the form of urgent arterial duplex of the index limb and/or computed tomography angiogram from the arch of the aorta to the bilateral lower limb, to find the site of occlusion and presence of atherosclerotic disease.

Procedure details – transfemoral/transpopliteal thrombectomy

All patients underwent emergency transfemoral or transpopliteal thrombectomy, under general anesthesia, through standard incisions and exposure. Fogarty catheters – 5 Fr, 4 Fr, and 3 Fr – were used for aortoiliac, femoropopliteal, and infrapopliteal arteries, respectively. Postthrombectomy on table digital subtraction angiogram was performed in all patients, and any significant underlying stenosis was treated by angioplasty/stenting. Four-compartment leg fasciotomy was performed based on clinical need.

Postoperative management

Postoperatively, patients were monitored in intensive care unit for 24 h and were continued on unfractionated heparin infusion. Activated clotting time was monitored every 4th hourly and maintained between 250 and 300. After 24 h postoperatively, anticoagulation was switched to low-molecular-weight heparin, which was continued for 2 weeks postdischarge and bridged over to oral anticoagulation (Vitamin K antagonists) which was continued for indefinitive period.

Follow-up

Patients were followed up at the 1st month, 3rd month, 6th month, and 1 year.

Data collection

All data were collected from our institutional database which includes demographics, comorbidities, time of presentation, procedural details, length of hospital stay, and perioperative and follow-up details.

Aims and objectives

The objective of this study was to compare postrevascularization limb salvage rate at 1 year between early presenting and delayed presenting Rutherford Class IIb acute lower limb ischemia patients.

Statistical analysis

Categorical variables were presented as counts and percentages, whereas continuous variables were presented as mean values ± standard deviations. Categorical variables were compared using the Fisher's exact test or Chi-square test. Continuous variables were compared using the unpaired t-test. P < 0.05 was considered to indicate a statistically significant difference. All statistical analysis was performed using SPSS software (version 20.0; IBM Corp., Armonk, NY, USA).


  Results Top


Demographics, lesion characteristics, and comorbidities were comparable among the two groups except distribution of ischemic heart disease which was significantly more in the early presenting group (P < 0.05). The mean age in the early presenting ALI group was 49.40 ± 10.68 years, whereas in the delayed presenting group, it was 49.14 ± 12.71 years. Majority of the patients in both the groups were male: 70% in the early presenting and 63.41% in the delayed presenting group. The most common site of occlusion in both the groups is femoropopliteal followed by tibial segment [Table 1]. The most common cause of ALI was thrombotic occlusion, observed in 40/51 patients (78.43%), whereas 11/51 patients (21.56%) had embolic etiology (3 in the early presenting group and 8 in the delayed presenting group). The distribution of thromboembolic ALI was comparable among the two groups.
Table 1: Demographics, lesion characteristic and co-morbidities/risk factors

Click here to view


The most commonly performed procedure in both the groups was transfemoral thrombectomy. In the delayed presenting group, 12.20% of the patients underwent transpopliteal thrombectomy. Additional endovascular intervention in terms of angioplasty ± stenting was done in 20% of the patients in the early presenting group and 26.83% in the delayed presenting group. Thrombolysis was done in only one patient in the delayed presenting group. Fasciotomy at the time of procedure or later was done in almost half of the patients in both the groups [Table 2].
Table 2: Procedural details

Click here to view


The limb salvage rate analyzed at the end of 1-year follow-up was 91.67% in the early presenting group, whereas in the delayed presenting group, it was 72.73%, but this observed difference was not statistically significant (P = 0.178) [Figure 2].
Figure 2: Limb salvage rate in the early and delayed presenting groups. “Y” axis shows limb salvage percentages and “X” axis shows time of presentation

Click here to view


No mortality was seen in the early presenting group, but 12.2% died in the late presenting group; the difference was not statistically significant. The mean length of hospital stay was comparable among both the groups: 5.8 ± 1.81 days in early whereas 7.05 ± 2.45 days in delayed presenting ALI, again not significant [Table 3].
Table 3: Mortality and length of hospital stay

Click here to view


Amputation analysis showed that the rate of major amputation in both the groups was comparable: 8.33% (one above-knee amputation) in the early presenting group and 27.27% (11 above-knee and 1 below-knee amputation) in the delayed presenting group. All major amputations in the early presenting group (1/12) were within 30 days of revascularization attributable to reocclusion, whereas in the delayed presenting group, 11/44 patients had amputation within 30 days and 1/44 patients had amputation from 30 days to 1 year due to either reocclusion or technical failure [Table 4].
Table 4: Amputation analysis

Click here to view



  Discussion Top


ALI is defined as any sudden decrease in limb perfusion causing a potential threat to limb viability.[5] Limb salvage mainly depends on time from onset of symptoms to revascularization.[6] However, in Indian scenario, most of the patients present late; hence, we evaluated the effect of revascularization on limb salvage in the early versus delayed presenting groups.

In our study, the overall 1-year limb salvage rate in immediately threatened lower limb ischemia is 76.78% (43/56); in the early presenting group, it was 91.67% (11/12), whereas in the delayed presenting group, it was 72.73% (32/44), though the observed difference is not significant. Our study shows early revascularization results in better limb salvage but also implies in spite of delayed presentation; good limb salvage rate can be achieved if revascularization attempt is given. The overall perioperative all-cause mortality in our study was 9.80%; none of the patients in the early presenting group had mortality, whereas in the delayed presenting group, the mortality rate was 12.20%. A similar retrospective study by Kempe et al.[7] included 170 acute lower extremity ischemia patients with majority (83%) presenting beyond 6 h observed 85% limb salvage rate at 3 months. In their study, 52% of the patients were in Rutherford Class IIb and the median time to amputation was 1 day and the 30-day mortality was 18%.

Khan and Nadeem [4] retrospectively studied 206 patients for the effect of revascularization on limb salvage in late presenting (>72 h) acute lower limb ischemia and found limb salvage rate of 86.90% at 6 months and mortality rate of 5.8%.

Kuukasjärvi and Salenius,[8] in their retrospective study of 509 acute lower limb ischemia patients, evaluated perioperative outcomes in terms of limb salvage, and mortality observed perioperative limb salvage rate of 84% and mortality of 13%.

The abovementioned studies in comparison to our study were summarized in [Table 5].
Table 5: Comparative analysis of limb salvage rate

Click here to view


Study limitations

The first limitation of our study is that the sample size was relatively small and the study design was retrospective in nature. The second most important limitation is that the functional status of salvaged limb is not taken into consideration; revascularization in delayed presenting lower limb ischemia may lead to various extents of sensory-motor deficit and thus affecting functional limb status.


  Conclusion Top


We conclude that in spite of delayed presentation of acute lower limb ischemia, especially in Indian scenario, good limb salvage can still be achieved if revascularization attempted.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wang SK, Murphy MP, Gutwein AR, Drucker NA, Dalsing MC, Motaganahalli RL, et al. Perioperative outcomes are adversely affected by poor pretransfer adherence to acute limb ischemia practice guidelines. Ann Vasc Surg 2018;50:46-51.  Back to cited text no. 1
    
2.
Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, et al. 2016 AHA/ACC Guideline on the Management of Patients with Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017;69:1465-508.  Back to cited text no. 2
    
3.
Nagarsheth KH, Nassiri N, Shafritz R, Rahimi S. Delayed revascularization for acute lower extremity ischemia leads to increased mortality. J Vasc Surg 2016;63:121S-2.  Back to cited text no. 3
    
4.
Khan MI, Nadeem IA. Revascularization of late-presenting acute limb ischaemia and limb salvage. J Ayub Med Coll Abbottabad 2016;28:262-6.  Back to cited text no. 4
    
5.
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG, et al. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg 2007;45 Suppl S: S5-67.  Back to cited text no. 5
    
6.
Rutherford RB, Baker JD, Ernst C, Johnston KW, Porter JM, Ahn S, et al. Recommended standards for reports dealing with lower extremity ischemia: Revised version. J Vasc Surg 1997;26:517-38.  Back to cited text no. 6
    
7.
Kempe K, Starr B, Stafford JM, Islam A, Mooney A, Lagergren E, et al. Results of surgical management of acute thromboembolic lower extremity ischemia. J Vasc Surg 2014;60:702-7.  Back to cited text no. 7
    
8.
Kuukasjärvi P, Salenius JP. Perioperative outcome of acute lower limb ischaemia on the basis of the national vascular registry. The finnvasc study group. Eur J Vasc Surg 1994;8:578-83.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

Top
 
 
  Search
 
Similar in PUBMED
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
   Materials and Me...
  Results
  Discussion
  Conclusion
   References
   Article Figures
   Article Tables

 Article Access Statistics
    Viewed67    
    Printed1    
    Emailed0    
    PDF Downloaded11    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]