|Year : 2020 | Volume
| 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
Hemant Kadu Chaudhari, Vivekanand, Vishnu Motukuru, KB Sumanthraj, S Roshan Rodney, Hudgi Vishal
Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India
|Date of Submission||17-Aug-2019|
|Date of Decision||15-Oct-2019|
|Date of Acceptance||04-Jan-2020|
|Date of Web Publication||16-Mar-2020|
Dr. Hemant Kadu Chaudhari
Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
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 Jul 14];7:58-62. Available from: http://www.indjvascsurg.org/text.asp?2020/7/1/58/280675
| Introduction|| |
Acute limb ischemia (ALI) is one of the most common vascular emergencies as it is both limb and life threatening.
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. 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.,
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|| |
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.
- 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
- >18 years old
- Rutherford Class IIb ischemia.
- Rutherford Class I, IIa, and III ischemia
- Prior vascular intervention
- Traumatic and iatrogenic ALI
- 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., 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].
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.
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.
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.
Patients were followed up at the 1st month, 3rd month, 6th month, and 1 year.
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.
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|| |
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|
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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].
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|
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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].
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].
| Discussion|| |
ALI is defined as any sudden decrease in limb perfusion causing a potential threat to limb viability. Limb salvage mainly depends on time from onset of symptoms to revascularization. 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. 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  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, 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].
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|| |
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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]