Vascular and wound healing outcomes after puncture of small or stenotic inframalleolar arteries in patients with chronic limb-threatening ischemia.

Abstract

This study evaluated the safety of below-the-ankle distal punctures, including stenotic or small-diameter inframalleolar arteries, on vessel integrity and wound healing in patients with chronic limb-threatening ischemia and infrapopliteal artery disease. This single-center, retrospective, nonrandomized, observational study analyzed 171 limbs from 155 patients (mean age, 76.1 ± 9.4 years; 74.2% with diabetes mellitus; 48.4% undergoing hemodialysis) with chronic limb-threatening ischemia (Rutherford classification 5-6) who underwent endovascular therapy using below-the-ankle distal punctures for de novo infrapopliteal disease (97.1% occlusion) between January 2014 and December 2024. Stenosis at puncture sites were observed in 83.0% of the cases, with a median vessel diameter of 1.8 mm. During a median follow-up of 13.1 months, the Kaplan-Meier-estimated 1-year wound healing rate was 57.3%. Chronic occlusion at puncture sites, defined as vessel occlusion after initial revascularization, occurred in 32.2% of the cases. Multivariate analysis identified renal failure on hemodialysis (odds ratio [OR], 2.76; 95% confidence interval [CI], 1.12-6.81; P = .028), the Global Limb Anatomical Staging System P2 modifier (OR, 2.89; 95% CI, 1.15-7.28; P = .024), and smaller distal puncture vessel sizes (scored as 0 [>2.0 mm], 1 [1.5-2.0 mm], or 2 [<1.5 mm]; OR, 10.8; 95% CI, 4.11-28.3; P < .001) as independent predictors of chronic occlusion at the puncture sites. The area under the receiver operating characteristic curve for vessel diameter in predicting chronic occlusion at the puncture site was 0.88, with the Youden J statistic indicating a cutoff value of 1.7 mm. Multivariate analysis showed that an increased foot infection grade (hazard ratio [HR], 0.71; 95% CI, 0.51-0.99; P = .043), a small artery disease score of 2 (HR, 0.54; 95% CI, 0.30-0.98; P = .042), and a chronic occlusion at the puncture site (HR, 0.51; 95% CI, 0.28-0.92; P = .025) were independent risk factors for impaired wound healing. Below-the-ankle distal punctures in stenotic arteries may cause puncture site occlusions before wound healing. If distal vessels at the puncture site supply the wound, close monitoring with Doppler or other imaging is essential to detect occlusions until the wound heals. When distal puncture is needed, selecting a target vessel with a larger diameter and minimal disease burden may lower the risk of chronic occlusions and help prevent delays in wound healing.