Impact of congestive heart failure on mid-term outcomes after lower extremity revascularization for peripheral artery disease.

Abstract

Congestive heart failure (CHF) and peripheral artery disease (PAD) often coexist, with worse outcomes in patients undergoing PAD procedures. We investigated the impact of CHF on mid-term mortality and postoperative outcomes after PAD interventions. Patients in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI)-Vascular Implant Surveillance and Interventional Outcomes Network (VISION) Medicare-linked database undergoing peripheral vascular interventions (PVIs) and lower extremity bypass (LEB) for PAD between 2010 and 2018 were grouped by CHF severity: Group 1, moderate/severe; and Group 2, none/asymptomatic/mild. We analyzed patients with chronic limb-threatening ischemia (CLTI) and intermittent claudication (IC) separately. Primary endpoints were 3-year death, major amputation, and reintervention. We performed propensity matching between groups. Kaplan-Meier, Cox proportional hazards, and Fine-Gray competing risk models were used to compare outcomes. Of 62,129 patients with PAD and CHF, 47,457 underwent PVI (IC, n = 19,741; CLTI, n = 27,716) and 14,672 underwent LEB (IC, n = 3688; CLTI, n = 10,984). Propensity matching was performed on 418 claudicants, 1516 patients with CLTI undergoing PVI, and 378 patients with CLTI undergoing LEB. There were very few claudicants (n = 52) in Group 1 who underwent LEB, and this group was not analyzed further. The median age was 71 years; around 70% were male, White, and had coronary artery disease. On Kaplan-Meier analyses, 3-year survival favored Group 2 after both PVI and LEB for CLTI and PVI for IC. After PVI for CLTI, Group 1 had worse freedom from major amputation. On Cox regression analyses, Group 1 was associated with worse 3-year mortality after both PVI and LEB for CLTI and PVI for IC. Fine-Gray analysis for patients with CLTI showed a lower reintervention rate in Group 1 after LEB with no difference in reintervention after PVI, and no difference in major amputation after PVI or LEB. Group 1 had a lower mortality risk at 3 years for patients with CLTI after LEB (65.3%) compared with PVI (70.5%) and a similar risk of reintervention and major amputation. CHF severity is a strong predictor of 30-day and mid-term mortality after both PVI and LEB for PAD. CHF severity did not significantly affect mid-term major or overall amputation. Conservative management should be strongly considered for claudicants with moderate to severe CHF. CHF severity by symptom status should be considered on an individualized basis when assessing preoperative risk, deciding revascularization strategy, and planning postoperative care.