Long-Term Results of the Treatment of Patients With Chronic Ischemia of the Lower Limbs in Combination With Ischemic Heart Disease.

Aim      To compare long-term outcomes of x-ray endovascular (percutaneous coronary intervention, PCI, and lower limb angioplasty with stent placement, LLA; group 1) and combination treatments (PCI and open LLA surgery; group 2) in patients with chronic lower limb ischemia (CLLI) associated with ischemic heart disease (IHD).Material and methods  This retrospective study has been conducted in the Vishnevsky National Medical Research Center of Surgery since 2019. The study includes 92 patients with stage 2B CLLI associated with IHD who were managed from January 1, 2017 through December 31, 2020. Long-term outcomes were evaluated in 76 (82.6 %) patients. The endpoint was severe cardiovascular complications (CVC), including death, myocardial infarction, and acute cerebrovascular disease (ACVD).Results In group 1 during the long-term period, 1 (2.7%) fatal outcome due to pneumonia was observed. In group 2, 4 (10 %) patients died: 1 (2.5 %) patient due to ACVD, 1 (2.5 %) patient due to progression of oncological process, and 2 2 (5 %) patients due to COVID-19. Also, 2 (5.5 %) and 1 (2.5 %) cases of acute coronary syndrome (ACS) were observed in groups 1 and 2, respectively (p=0.61).Conclusion      In the x-ray endovascular (group1) and the combination (group 2) intervention groups, lethal outcomes due to myocardial infarction were absent. This fact confirms the importance of PCI in patients with CLLI for prevention of possible ACS in the long-term. Both therapeutic tactics in managing CLLI patients with IHD demonstrated high safety and clinical efficacy during the hospital and long-term periods and can be extensively used in routine clinical practice.

Long-term results of surgical treatment of patients with chronic and critical lower limb ischemia depending on myocardial revascularization

Objective: to determine the efficacy and safety of preoperative selective coronary angiography and myocardial revascularization (according to indications) during long-term follow-up in patients with chronic ischemia of the lower limbs 2B–4 stage, who underwent open surgical interventions. Material and methods. From 2015 to 2018 at the Vishnevskiy National Medical Research Center of Surgery were treated 169 patients with chronic lower limb ischemia of stage 2B–4 according to the Fontaine–Pokrovsky classification. Depending on preliminary selective coronary angiography, the patients were divided into two groups: group 1 (n = 96) – surgical treatment of chronic ischemia of the lower limbs 2B–4 stage without preliminary coronary angiography;group 2 (n = 73) – surgical treatment of chronic ischemia of the lower limbs 2B–4 stage with preliminary coronary angiography and myocardial revascularization in the presence of significant lesions of the coronary arteries. Based on the coronary angiography performed by all, 60 (82.1%) patients were diagnosed with lesions of at least one coronary artery more than 50%. The study included 144 (85.2%) men and 25 (14.8%) women. In group 1, 55 (57.2%) out of 96 patients were with chronic ischemia of the lower limbs 3–4 stage, and in group 2, 42 (57.5%) out of 73. Type 2 diabetes mellitus was present in 21 (21.8%) patients in group 1, and in 18 (24.6%) in group 2. Both groups had similar clinical characteristics (p > 0.05). In the hospital and long-term follow-up periods, the primary endpoints of the study were death from major cardiovascular complications, myocardial infarction (MI), acute cerebrovascular accident (ACA), transient ischemic attack. Secondary endpoints included repeated revascularization of the myocardium or arteries of the lower extremities, amputation of the lower limb. A total of 224 operations were performed in 169 patients (1.3 operations per 1 patient): 169 – on the arteries of the lower extremities, 55 – percutaneous coronary intervention/coronary artery bypass grafting. Results. Long-term results were analyzed in 145 (85.7%) patients: 79 (54.4%) – in group 1 and 66 (45.6%) – in group 2. During the follow-up period (on average 50 ± 2 months), the total mortality from all causes was 20 (13.7%) cases. In group 1, 11 (13.9%) deaths were noted: in 6 (7.5%) – due to myocardial infarction, in 3 (3.7%) – ACA, in 1 (1.2%) – due to cancer, in 1 (1.2%) – gangrene of the lower extremities with intoxication and multiple organ failure syndrome. In group 2, 9 (13.6%) deaths were noted: in 3 (4.5%) – due to cancer, in 2 (3.0%) – ACA, in 1 (1.5%) – pulmonary embolism, in 3 (4.5%) – COVID-19. Also, in group 1 there were 3 (3.7%) myocardial infarctions and one (1.2%) ACA without a fatal outcome, while in group 2 there was only 1 (1.5%) MI. At the secondary endpoints in the long-term period, 3 (3.7%) patients underwent percutaneous coronary intervention in group 1 and 5 (7.5%) – in group 2. In 13 patients of both groups (16.4 and 19.6%), repeated surgery was performed on the arteries of the lower extremities. Additionally, in group 1, 8 (9.0%) patients underwent amputation of the lower limb, and in group 2 – in 6 (9.0%). Conclusion. Performing coronary angiography with subsequent myocardial revascularization (according to indications) in patients with chronic ischemia of the lower limbs stage 2B–4, aimed at open surgical revascularization of the arteries of the lower extremities, in the long-term period leads to a significant decrease in the frequency of fatal myocardial infarctions (p = 0.023), as well as the total number of myocardial infarctions (p = 0.021). Patients who underwent and did not undergo coronary angiography did not receive a significant difference in the long-term period in terms of death from MI and ACA (p = 0.058). Considering the above, the results of our study show the effectiveness of performing coronary angiography with subsequent myocardial revascularization, in order to reduce cardiovascular complications in the ong term. Coronary angiography can be one of the methods of screening for coronary artery disease in these patients, if it is impossible to perform non-invasive methods for detecting and visualizing myocardial ischemia. © 2022 Ministry of Health. All rights reserved.