Patients with peripheral artery disease (PAD) and a history of lower extremity revascularization (LER) face an increased risk of both cardiac and limb ischemic events and subsequent revascularization, according to research published in the Journal of the American College of Cardiology Oct. 2.
Lower extremity PAD is common in heart patients, first author Iris Baumgartner, MD, and colleagues wrote in JACC, but trials exploring the clinical outcomes of LER have come back with inconsistent results. Despite the use of LER nearly doubling between 1996 and 2006, and major lower extremity amputations falling by more than 25 percent as a result, current guidelines for the treatment rely heavily on anatomical details rather than clinical characteristics and prognostic factors of individual patients.
“A large and increasing number of patients with PAD are currently offered LER, with rapid development of modern, minimally invasive endovascular revascularization techniques,” Baumgartner, of the Swiss Cardiovascular Center at the University of Bern in Bern, Switzerland, and co-authors said. “This shift in clinical practice is presumably not related to a change in the patterns or natural history of PAD, but rather appears to be due to the continued evolution of technology available for endovascular treatment.”
Baumgartner and her team analyzed a total of 13,885 patients with symptomatic PAD for their study, 12.5 percent of whom received a post-randomization LER. Patients were enrolled from the EUCLID database.
The authors found endovascular LERs—which comprised 74.7 percent of all post-randomization LERs in the study population—were performed more often in North America, while surgical procedures were performed more frequently in Europe. Post-randomization LER was associated with a 1.6-fold increased risk for the study’s primary endpoint of myocardial infarction, ischemic stroke or cardiovascular death, as well as a 12-fold increased risk of major adverse limb events (MALEs).
“Independent factors associated with post-randomization LER indicated that the greatest risk was in patients who had a prior history of LER at baseline; this risk was graded and was highest in patients with a prior history of both surgical and endovascular procedures,” Baumgartner et al. wrote. “In addition, factors associated with post-randomization LER that were statistically significant included the presence of limb symptoms, diabetes, current or former tobacco use and geographic region of enrollment.”
Major outcomes, including an increased risk for the primary endpoint, acute limb ischemia requiring hospitalization, major amputations and cardiovascular death were all more common after a post-randomization LER, they said.
“In patients with PAD, a history of lower extremity revascularization is associated with a heightened risk of both cardiac and limb ischemic events and subsequent revascularization,” the authors wrote. “Further studies are needed to explain the variation in risk related to geographic region of care and to develop treatment strategies that reduce the risk of recurrent ischemic events in this vulnerable population.”
After graduating from Indiana University-Bloomington with a bachelor’s in journalism, Anicka joined TriMed’s Chicago team in 2017 covering cardiology. Close to her heart is long-form journalism, Pilot G-2 pens, dark chocolate and her dog Harper Lee.