Objective: This study investigated the effect of patency of the pedal arch (PA) on wound healing rate and time, amputation-free survival (AFS), limb salvage, and limb-based patency (LBP) in chronic limb-threatening ischemia (CLTI) patients undergoing endovascular revascularization of infrainguinal arterial lesions.
Methods: This prospective study included all CLTI patients presented with wound, ischemia, and foot infection (WIFI) stages 2-4 (WIFI ischemia grades 2-3) who underwent endovascular revascularization of infrainguinal arterial disease between April 2019 and April 2021. Pedal angioplasty was attempted in all patients with significant steno-occlusive pedal artery disease. Patients were stratified according to Kawarada PA types. Successful pedal arch revascularization (PAR) was counted when at least one pedal vessel is patent. Wound healing rate and time, and Kaplan-Meier estimate of AFS and LBP at 2 years were evaluated and compared among the patient groups.
Results: A total of 120 patients were categorized according to PA type into type1 (n=34, 28.3%), type 2 (n=64, 53.3%), and type 3 (n=22, 18.3%). Pedal angioplasty was attempted in 97 patients and was technically successful in 75 (77.3%) patients. Successful PAR (with or without pedal angioplasty) was achieved in 98 patients (81.7%). During the follow-up, successful PAR resulted in better wound healing rate (86.7% vs 59.1%, P = 0.007), major amputation rates (5.1% vs 40.9%, P=<0.001), and AFS (92.9% vs. 72.7%; P=0.018) compared to unsuccessful PAR. There were no significant differences between the two groups in wound healing time (3.76 months ± 1.99 vs 3.64 ± 1.94, P=0.798, respectively) or LBP (80.6% vs 72.7%, P=0.594, respectively). GLASS stage (OR, 6.84; 95% CI: 1.30-36.03, P = 0.023) and unsuccessful PAR (OR, 21.64; 95% CI: 4.01-116.69, P = <0.001) were independently associated with failure of wound healing, while site of wound lesion (OR, 5.52; 95% CI: 1.15-26.48, P=0.033), GLASS stage (OR, 24.93; 95% CI: 2.84-218.69, P=0.004), and unsuccessful PAR (OR, 22.44; 95% CI: 3.53-142.67, P=0.001) were significant predictors of major amputation.
Conclusion
Successful PAR is important for improving clinical outcomes of endovascular revascularization of CLTI patients such as wound healing, amputation-free survival, and limb salvage. Predictors of limb salvage were site of foot lesion, GLASS staging, and successful PAR, while GLASS staging and successful PAR were independently associated with improved wound healing.
 
Keywords: Critical limb-threatening ischemia, pedal artery, endovascular procedures
amputation, survival, prognosis