Outcomes Following Open Lower Extremity Revascularization after Previous Interventions in Patients with Critical Limb Ischemia.

Abstract Introduction For decades, open intervention was the treatment of choice in patients requiring lower extremity revascularization. In the endovascular era, however, open or endovascular revascularization are options. The implications of prior revascularization on the outcomes for subsequent revascularization are not known. In the current study, we evaluated 30-day outcomes after open lower extremity revascularization for critical limb ischemia (CLI) in those that have had previous interventions. Methods The 2012-2017 open lower extremity bypass Participant User Data Files from the National Surgical Quality Improvement Program (NSQIP) were used to identify a cohort of patients with CLI. Patients whose operation was considered emergent were excluded from the analysis. Patients were stratified on whether they had a previous open or endovascular intervention or undergoing a primary revascularization. The primary outcome measure was 30-day major adverse limb events (MALE). Secondary outcomes included major adverse cardiac events (MACE) and wound complications. Results A total of 12,668 patients met study criteria with 59.6% (n=7,549) undergoing a primary open revascularization, 22.4% (n=2,839) having a prior endovascular intervention, and 18.0% (n=2,280) having a prior open revascularization. There were notable differences in the baseline characteristics between the three groups. In addition, there were differences in the reason for intervention (rest pain versus tissue loss), type of revascularization, and type of conduit used between the three groups. After adjustment, a prior open revascularization was significantly associated with 30-day MALE when compared to a primary revascularization (aOR 1.69, 95% CI 1.47-1.94, P Conclusion A prior endovascular intervention does not seem to accrue any additional short-term risk when compared to primary revascularization, suggesting an endovascular-first approach may be a safe-strategy in CLI patients. However, a prior open intervention is significantly associated with 30-day MALE in patients undergoing redo open revascularization, which may be related to the rapid decline of patients once they have exhausted their best open revascularization option.